Provider Demographics
NPI:1871657270
Name:MARTIN, MELVIN H (DMD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:H
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 1:1165 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1662
Mailing Address - Country:US
Mailing Address - Phone:217-285-5525
Mailing Address - Fax:217-285-5526
Practice Address - Street 1:1165 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1662
Practice Address - Country:US
Practice Address - Phone:217-285-5525
Practice Address - Fax:217-285-5526
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-159411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice