Provider Demographics
NPI:1720150402
Name:MISIURA, MARTIN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:C
Last Name:MISIURA
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 1:418 LACKAWANNA AVE
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1524
Mailing Address - Country:US
Mailing Address - Phone:570-489-5611
Mailing Address - Fax:570-489-3388
Practice Address - Street 1:418 LACKAWANNA AVE
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-1524
Practice Address - Country:US
Practice Address - Phone:570-489-5611
Practice Address - Fax:570-489-3388
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA025729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist