Provider Demographics
NPI:1841208733
Name:MARTIN, ELMER GARNEL (DMD)
Entity Type:Individual
Prefix:MR
First Name:ELMER
Middle Name:GARNEL
Last Name:MARTIN
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:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90733-0102
Mailing Address - Country:US
Mailing Address - Phone:510-437-3616
Mailing Address - Fax:
Practice Address - Street 1:1001 S SEASIDE AVE # BLDGE23
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731
Practice Address - Country:US
Practice Address - Phone:310-521-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist