Provider Demographics
NPI:1659440659
Name:MARTIN, MYRA I (DMD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:I
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:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-0348
Mailing Address - Country:US
Mailing Address - Phone:787-854-7560
Mailing Address - Fax:
Practice Address - Street 1:CALLE G-16 ALTOS
Practice Address - Street 2:URB. FLAMBOYAN
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice