Provider Demographics
NPI:1669621140
Name:MARTHA JO BRAID DMD LLC
Entity type:Organization
Organization Name:MARTHA JO BRAID DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-540-5100
Mailing Address - Street 1:2801-7 CIVIC CIRCLE BLVD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-998-9868
Mailing Address - Fax:618-998-9870
Practice Address - Street 1:2801-7 CIVIC CIRCLE BLVD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-9868
Practice Address - Fax:618-998-9870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTHA JO BRAID DMD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty