MEDICARE: DR. JORDAN MARTIN D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN19896	FL

General Provider Information

NPI Number	:	1558617316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN MARTIN D.D.S.

Provider Business Mailing Address
First Line	:	9136 BONITA BEACH RD SE
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-4281
Country	:	US
Telephone Number	:	239-992-9229
Fax Number	:

Provider Business Practice Location Address
First Line	:	9136 BONITA BEACH RD SE
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-4281
Country	:	US
Telephone Number	:	239-992-9229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	08/21/2012

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