Provider Demographics
NPI:1518290980
Name:DOUGLAS R. MARTIN DDS SC
Entity Type:Organization
Organization Name:DOUGLAS R. MARTIN DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-406-9399
Mailing Address - Street 1:1808 W GLEN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2902
Mailing Address - Country:US
Mailing Address - Phone:616-406-9399
Mailing Address - Fax:
Practice Address - Street 1:2905 S 12TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6705
Practice Address - Country:US
Practice Address - Phone:616-406-9399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2602-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty