Provider Demographics
NPI:1457767923
Name:MARTIN, QUINN (DMD)
Entity Type:Individual
Prefix:
First Name:QUINN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1683 W HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2812
Mailing Address - Country:US
Mailing Address - Phone:541-706-9445
Mailing Address - Fax:
Practice Address - Street 1:1683 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2812
Practice Address - Country:US
Practice Address - Phone:541-706-9445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD46031223G0001X
ORD102191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice