Provider Demographics
NPI:1952662132
Name:MARTIN, DEREK MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MICHAEL
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 1:1259 HYDE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2817
Mailing Address - Country:US
Mailing Address - Phone:508-579-8698
Mailing Address - Fax:
Practice Address - Street 1:1259 HYDE PARK AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-2817
Practice Address - Country:US
Practice Address - Phone:617-364-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855962122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist