Provider Demographics
NPI:1972799567
Name:MARTIN, JUSTIN D
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 FIRST COLONIAL RD
Mailing Address - Street 2:STE #201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2207
Mailing Address - Country:US
Mailing Address - Phone:757-333-3399
Mailing Address - Fax:757-333-4946
Practice Address - Street 1:1200 FIRST COLONIAL RD
Practice Address - Street 2:SUITE #201
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2207
Practice Address - Country:US
Practice Address - Phone:757-333-3399
Practice Address - Fax:757-333-4946
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086141223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics