Provider Demographics
NPI:1629230644
Name:MARTIN PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:MARTIN PEDIATRIC DENTISTRY, LLC
Other - Org Name:MIGHTY MOUTHS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TU-WANDA
Authorized Official - Middle Name:MARABLE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-627-0029
Mailing Address - Street 1:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-0962
Mailing Address - Country:US
Mailing Address - Phone:864-627-0029
Mailing Address - Fax:
Practice Address - Street 1:218 NEW NEELY FERRY RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2615
Practice Address - Country:US
Practice Address - Phone:864-627-0029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty