Provider Demographics
NPI:1508860040
Name:MARTIN, JOHN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 CARNEGIE DR
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1157
Mailing Address - Country:US
Mailing Address - Phone:814-234-4997
Mailing Address - Fax:814-234-4997
Practice Address - Street 1:2521 CARNEGIE DR
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-1157
Practice Address - Country:US
Practice Address - Phone:814-234-4997
Practice Address - Fax:814-234-4997
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018149L1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics