Provider Demographics
NPI:1659555811
Name:MARTINDALE, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:MARTINDALE
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 104
Mailing Address - Street 2:
Mailing Address - City:EXPERIMENT
Mailing Address - State:GA
Mailing Address - Zip Code:30212-0104
Mailing Address - Country:US
Mailing Address - Phone:954-554-4746
Mailing Address - Fax:
Practice Address - Street 1:1528 LUCKY ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1176
Practice Address - Country:US
Practice Address - Phone:770-637-5876
Practice Address - Fax:770-228-5564
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17886122300000X
GADN014482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist