Provider Demographics
NPI:1588820799
Name:MARTIN, THOMAS ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ANTHONY
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 1:10744 GOWANDA STATE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14111-9510
Mailing Address - Country:US
Mailing Address - Phone:716-337-3383
Mailing Address - Fax:
Practice Address - Street 1:135 MEADOW LN
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14223-1365
Practice Address - Country:US
Practice Address - Phone:716-908-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0538851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03167571Medicaid