Healthcare Provider Details

I. General information

NPI: 1457323412
Provider Name (Legal Business Name): JAMES CAREY MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 CRAVEN ST
SAN DIEGO CA
92136-5596
US

IV. Provider business mailing address

254 J AVE
CORONADO CA
92118-1138
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-8255
  • Fax:
Mailing address:
  • Phone: 360-271-8865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD8376
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: