Provider Demographics
NPI:1689235681
Name:PHANDL, MARTIN D
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:D
Last Name:PHANDL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 E HILLSDALE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1293
Mailing Address - Country:US
Mailing Address - Phone:650-574-3612
Mailing Address - Fax:
Practice Address - Street 1:1291 E HILLSDALE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1293
Practice Address - Country:US
Practice Address - Phone:650-574-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352291223G0001X
CA1051411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice