Provider Demographics
NPI:1760532139
Name:ESPE, MARTY J (DDS, MD)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:J
Last Name:ESPE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-4046
Mailing Address - Country:US
Mailing Address - Phone:218-722-8377
Mailing Address - Fax:218-722-3117
Practice Address - Street 1:3617 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4046
Practice Address - Country:US
Practice Address - Phone:218-722-8377
Practice Address - Fax:218-722-3117
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111001223S0112X
WI50061223S0112X
MN40391204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33751200OtherWISCONSIN MEDICAID
MN49Q57ESOtherMINNESOTA BCBS
MN749215400Medicaid
WI0003Medicare PIN
MN850000045Medicare PIN
MN850000020Medicare PIN
WI33751200OtherWISCONSIN MEDICAID
MN749215400Medicaid