Provider Demographics
NPI:1801911375
Name:MARTIN, SCOTT DEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DEAN
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 1:224 W GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-3343
Mailing Address - Country:US
Mailing Address - Phone:217-348-1610
Mailing Address - Fax:217-348-1615
Practice Address - Street 1:224 W GRANT AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-3343
Practice Address - Country:US
Practice Address - Phone:217-348-1610
Practice Address - Fax:217-348-1615
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice