Provider Demographics
NPI:1336571611
Name:MARTIN KIDS DENTAL HEALTH TEAM
Entity Type:Organization
Organization Name:MARTIN KIDS DENTAL HEALTH TEAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-371-3200
Mailing Address - Street 1:13820 W NEWBERRY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32669-2093
Mailing Address - Country:US
Mailing Address - Phone:352-371-3200
Mailing Address - Fax:352-377-7102
Practice Address - Street 1:13820 W NEWBERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:JONESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32669
Practice Address - Country:US
Practice Address - Phone:352-371-3200
Practice Address - Fax:352-377-7102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20184122300000X
FL194621223P0221X
FLDN72981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty