Provider Demographics
NPI:1841279783
Name:MARTIN, LAURA T (DDS ORTHODONTIST)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:T
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS ORTHODONTIST
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:T
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS ORTHODONTIST
Mailing Address - Street 1:3240 CORLEAR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463
Mailing Address - Country:US
Mailing Address - Phone:718-601-3910
Mailing Address - Fax:718-432-7103
Practice Address - Street 1:3240 CORLEAR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463
Practice Address - Country:US
Practice Address - Phone:718-601-3910
Practice Address - Fax:718-432-7103
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03918211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00919860Medicaid