Provider Demographics
NPI:1568528297
Name:MARTIN, SANDRA ELIZABETH (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 DR CALVIN JONES HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3104
Mailing Address - Country:US
Mailing Address - Phone:919-488-3384
Mailing Address - Fax:919-488-3385
Practice Address - Street 1:610 DR CALVIN JONES HWY
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3101
Practice Address - Country:US
Practice Address - Phone:919-488-3384
Practice Address - Fax:919-488-3384
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC65881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC799002GMedicaid