Provider Demographics
NPI:1255592267
Name:MARTIN, MITISHA NICHOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:MITISHA
Middle Name:NICHOLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MITISHA
Other - Middle Name:NICHOLE
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:5316 S. 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214
Mailing Address - Country:US
Mailing Address - Phone:502-276-8778
Mailing Address - Fax:
Practice Address - Street 1:5316 S. 3RD STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214
Practice Address - Country:US
Practice Address - Phone:502-276-8778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8651122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist