Provider Demographics
NPI:1134385818
Name:MARTIN, PAMELA R (DMD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 WEEPING WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-2313
Mailing Address - Country:US
Mailing Address - Phone:904-814-8964
Mailing Address - Fax:
Practice Address - Street 1:13 SAINT JOHNS MEDICAL PK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5304
Practice Address - Country:US
Practice Address - Phone:904-471-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist