Provider Demographics
NPI:1750720694
Name:MARTIN, GREGORY LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:LYNN
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 1:301 E STADIUM
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2034
Mailing Address - Country:US
Mailing Address - Phone:870-901-7645
Mailing Address - Fax:870-234-2030
Practice Address - Street 1:301 E STADIUM
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2034
Practice Address - Country:US
Practice Address - Phone:870-901-7645
Practice Address - Fax:870-234-2030
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR39471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice