Provider Demographics
NPI:1184749822
Name:JUSTIN D MARTIN DDS PC
Entity type:Organization
Organization Name:JUSTIN D MARTIN DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-333-3399
Mailing Address - Street 1:1200 FIRST COLONIAL ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454
Mailing Address - Country:US
Mailing Address - Phone:757-333-3399
Mailing Address - Fax:757-333-4946
Practice Address - Street 1:1200 FIRST COLONIAL ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454
Practice Address - Country:US
Practice Address - Phone:757-333-3399
Practice Address - Fax:757-333-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086141223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
845982OtherUNITED CONCORDIA