Provider Demographics
NPI:1902813348
Name:MARTIN, VERNON ARTHUR (LD)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:ARTHUR
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21506 NE LACHENVIEW LN
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-9737
Mailing Address - Country:US
Mailing Address - Phone:503-667-8053
Mailing Address - Fax:
Practice Address - Street 1:10102 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4456
Practice Address - Country:US
Practice Address - Phone:503-257-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0516028598122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0516028598OtherLICENSED DENTURIST