Provider Demographics
NPI:1750675419
Name:MARTIN, JARRELL RICHARD II (DDS)
Entity Type:Individual
Prefix:DR
First Name:JARRELL
Middle Name:RICHARD
Last Name:MARTIN
Suffix:II
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 1:1218 VIRGINIA ST E
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2951
Mailing Address - Country:US
Mailing Address - Phone:304-342-4422
Mailing Address - Fax:
Practice Address - Street 1:1218 VIRGINIA ST E
Practice Address - Street 2:SUITE D
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2951
Practice Address - Country:US
Practice Address - Phone:304-342-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038966122300000X
WV39451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist