Provider Demographics
NPI:1770801094
Name:MARTIN, PAMELA S (RDH WITH LAP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDH WITH LAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16300 HIGHWAY 62
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-7858
Mailing Address - Country:US
Mailing Address - Phone:541-621-6094
Mailing Address - Fax:
Practice Address - Street 1:16300 HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524-7858
Practice Address - Country:US
Practice Address - Phone:541-621-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4261124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist