Provider Demographics
NPI:1891966404
Name:MARTIN, ROBERT ANDREW (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ANDREW
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WALKER WAY
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759
Mailing Address - Country:US
Mailing Address - Phone:662-323-3801
Mailing Address - Fax:662-323-3121
Practice Address - Street 1:101 WALKER WAY
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-323-3801
Practice Address - Fax:662-323-3121
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-22
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5441122300000X
MS3528-09122300000X
MSOS-427-101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist