Provider Demographics
NPI:1992381594
Name:CRYSTAL MARTIN DDS
Entity Type:Organization
Organization Name:CRYSTAL MARTIN DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:LUCILLE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-227-0507
Mailing Address - Street 1:277 CLARKSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2280
Mailing Address - Country:US
Mailing Address - Phone:636-227-0507
Mailing Address - Fax:636-591-0032
Practice Address - Street 1:277 CLARKSON RD STE 100
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2280
Practice Address - Country:US
Practice Address - Phone:636-227-0507
Practice Address - Fax:636-591-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental