Provider Demographics
NPI:1487004537
Name:MARTIN, BRENDA LEE (DMD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E STRONG ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-2979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E STRONG ST
Practice Address - Street 2:SUITE 4
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-2979
Practice Address - Country:US
Practice Address - Phone:847-947-2651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist