Provider Demographics
NPI:1780794883
Name:MARTINI, PHILLIP JOHN (DDS)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOHN
Last Name:MARTINI
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 1:636 CHURCH ST
Mailing Address - Street 2:# 501
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-491-0203
Mailing Address - Fax:847-491-1210
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:# 501
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-491-0203
Practice Address - Fax:847-491-1210
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002861Medicaid