Provider Demographics
NPI:1245324417
Name:MARTIN DENTAL CLINIC PA
Entity type:Organization
Organization Name:MARTIN DENTAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-869-2787
Mailing Address - Street 1:PO BOX 1405
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866
Mailing Address - Country:US
Mailing Address - Phone:662-869-2787
Mailing Address - Fax:662-869-2728
Practice Address - Street 1:179 MOBILE ST
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866
Practice Address - Country:US
Practice Address - Phone:662-869-2787
Practice Address - Fax:662-869-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS218685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty