Provider Demographics
NPI:1578526208
Name:MARTIN, EDWARD JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
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 1:1302 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47932
Mailing Address - Country:US
Mailing Address - Phone:765-793-4680
Mailing Address - Fax:765-793-0513
Practice Address - Street 1:1302 PEARL ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:IN
Practice Address - Zip Code:47932
Practice Address - Country:US
Practice Address - Phone:765-793-4680
Practice Address - Fax:765-793-0513
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006965122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1001169900Medicaid