Provider Demographics
NPI:1639223233
Name:GAMBLE, MARTY E (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTY
Middle Name:E
Last Name:GAMBLE
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 1:136 EAST PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:KY
Mailing Address - Zip Code:42217
Mailing Address - Country:US
Mailing Address - Phone:270-424-5999
Mailing Address - Fax:270-424-5522
Practice Address - Street 1:136 EAST PRINCETON ST
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:KY
Practice Address - Zip Code:42217
Practice Address - Country:US
Practice Address - Phone:270-424-5999
Practice Address - Fax:270-424-5522
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY75231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000304Medicaid