Healthcare Provider Details

I. General information

NPI: 1609812999
Provider Name (Legal Business Name): DONOVAN TROY MARTIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 CANYON BLVD
BOULDER CO
80302-5407
US

IV. Provider business mailing address

630 HARTFORD DR
BOULDER CO
80305-5717
US

V. Phone/Fax

Practice location:
  • Phone: 303-245-0403
  • Fax: 303-245-0405
Mailing address:
  • Phone: 720-771-7309
  • Fax: 303-245-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9087
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: