Provider Demographics
NPI:1750507679
Name:DEMARTINO, EDWARD L (DMD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:DEMARTINO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-1328
Mailing Address - Country:US
Mailing Address - Phone:724-459-6340
Mailing Address - Fax:724-459-6922
Practice Address - Street 1:30 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-1328
Practice Address - Country:US
Practice Address - Phone:724-459-6340
Practice Address - Fax:724-459-6922
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-029130-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA597230OtherUNITED CONCORDIA
PA76779Medicaid