Provider Demographics
NPI:1770709701
Name:MARTIN, JEFFREY R (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:R
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 1:24 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-3454
Mailing Address - Country:US
Mailing Address - Phone:716-652-3960
Mailing Address - Fax:716-652-6125
Practice Address - Street 1:950 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-1924
Practice Address - Country:US
Practice Address - Phone:716-652-3960
Practice Address - Fax:716-652-6125
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0401701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice