Provider Demographics
NPI:1588677082
Name:MARTIN, GREGORY PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
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 1:2502 GALEN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-7045
Mailing Address - Country:US
Mailing Address - Phone:217-359-3925
Mailing Address - Fax:
Practice Address - Street 1:1210 LANCASTER DRIVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-7028
Practice Address - Country:US
Practice Address - Phone:217-359-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190214541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice