Provider Demographics
NPI:1841342680
Name:MARTIN, TOMMY R (DDS)
Entity type:Individual
Prefix:DR
First Name:TOMMY
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 1:650 CHESTNUT ST # 2
Mailing Address - Street 2:
Mailing Address - City:HICKMAN
Mailing Address - State:NE
Mailing Address - Zip Code:68372-9764
Mailing Address - Country:US
Mailing Address - Phone:402-792-3000
Mailing Address - Fax:402-792-3500
Practice Address - Street 1:650 CHESTNUT ST # 2
Practice Address - Street 2:
Practice Address - City:HICKMAN
Practice Address - State:NE
Practice Address - Zip Code:68372-9764
Practice Address - Country:US
Practice Address - Phone:402-792-3000
Practice Address - Fax:402-792-3500
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025549700Medicaid
NE4945OtherLICENSE