Provider Demographics
NPI:1760810444
Name:MARTIN, DDS PLLC
Entity Type:Organization
Organization Name:MARTIN, DDS PLLC
Other - Org Name:YOUNG SMILES WV
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JARREL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-419-0125
Mailing Address - Street 1:140 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25303
Mailing Address - Country:US
Mailing Address - Phone:304-342-4422
Mailing Address - Fax:304-400-4986
Practice Address - Street 1:140 7TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTOWN
Practice Address - State:WV
Practice Address - Zip Code:25303
Practice Address - Country:US
Practice Address - Phone:304-342-4422
Practice Address - Fax:304-400-4986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3945122300000X
WV38271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000582Medicaid