Provider Demographics
NPI:1457394819
Name:MARTINE, GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:MARTINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:NIKI
Other - Middle Name:
Other - Last Name:MARTINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 78665
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-0665
Mailing Address - Country:US
Mailing Address - Phone:317-291-2119
Mailing Address - Fax:317-291-2120
Practice Address - Street 1:3410 W 56TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-1606
Practice Address - Country:US
Practice Address - Phone:317-291-2119
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120091931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice