Provider Demographics
NPI:1932300977
Name:MARTIN, BRYAN BARRET (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:BARRET
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 1:405 N CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-2609
Mailing Address - Country:US
Mailing Address - Phone:601-783-2606
Mailing Address - Fax:601-783-2617
Practice Address - Street 1:405 N CLARK AVE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2609
Practice Address - Country:US
Practice Address - Phone:601-783-2606
Practice Address - Fax:601-783-2617
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3453-081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07575621Medicaid
TX1840399-01Medicaid