Provider Demographics
NPI:1710278429
Name:BRYAN B. MARTIN, DMD, LLC
Entity Type:Organization
Organization Name:BRYAN B. MARTIN, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-783-2606
Mailing Address - Street 1:405 N CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-2609
Mailing Address - Country:US
Mailing Address - Phone:601-783-2606
Mailing Address - Fax:601-783-0572
Practice Address - Street 1:405 N CLARK AVE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2609
Practice Address - Country:US
Practice Address - Phone:601-783-2606
Practice Address - Fax:601-783-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3453.081223G0001X
TX224741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1932300977OtherINDIVIDUAL NPI
MS07575621Medicaid