Provider Demographics
NPI:1891159299
Name:W ERIC MARTIN DDS PC
Entity Type:Organization
Organization Name:W ERIC MARTIN DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-355-9997
Mailing Address - Street 1:403 E WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7722
Mailing Address - Country:US
Mailing Address - Phone:217-355-9997
Mailing Address - Fax:
Practice Address - Street 1:403 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-355-9997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0600074081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty