Provider Demographics
NPI:1619248994
Name:JEANNE E MARTIN, DMD
Entity Type:Organization
Organization Name:JEANNE E MARTIN, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-528-3540
Mailing Address - Street 1:406 MASTER ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-1054
Mailing Address - Country:US
Mailing Address - Phone:606-528-3540
Mailing Address - Fax:606-528-0424
Practice Address - Street 1:406 MASTER ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1054
Practice Address - Country:US
Practice Address - Phone:606-528-3540
Practice Address - Fax:606-528-0424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY617800Medicaid