Healthcare Provider Details

I. General information

NPI: 1215073804
Provider Name (Legal Business Name): DANIEL CLAYTON MARTIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40165 TRUCKEE AIRPORT RD STE 303
TRUCKEE CA
96161-4113
US

IV. Provider business mailing address

40165 TRUCKEE AIRPORT RD STE 303
TRUCKEE CA
96161-4113
US

V. Phone/Fax

Practice location:
  • Phone: 530-587-5440
  • Fax:
Mailing address:
  • Phone: 530-587-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberS2-103
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number54665
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number54665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: