Provider Demographics
NPI:1639582943
Name:MARTIN, SHAKELA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHAKELA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 6TH AVE S STE 500
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4200
Mailing Address - Country:US
Mailing Address - Phone:904-224-3550
Mailing Address - Fax:
Practice Address - Street 1:850 6TH AVE S STE 500
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4200
Practice Address - Country:US
Practice Address - Phone:904-224-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015049300Medicaid