Provider Demographics
NPI:1700052784
Name:MARTIN, WYMAN B (DDS)
Entity Type:Individual
Prefix:
First Name:WYMAN
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 W CROSSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2964
Mailing Address - Country:US
Mailing Address - Phone:770-993-7424
Mailing Address - Fax:678-461-4436
Practice Address - Street 1:45 W CROSSVILLE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2964
Practice Address - Country:US
Practice Address - Phone:770-993-7424
Practice Address - Fax:678-461-4436
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice