Provider Demographics
NPI:1639215684
Name:MARTIN, JOHN PATRICK (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
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:PO BOX 581
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-0581
Mailing Address - Country:US
Mailing Address - Phone:304-201-8500
Mailing Address - Fax:304-201-8505
Practice Address - Street 1:3659 TEAYS VALLEY ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9701
Practice Address - Country:US
Practice Address - Phone:304-201-8500
Practice Address - Fax:304-201-8505
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV32641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0134667000Medicaid