Healthcare Provider Details

I. General information

NPI: 1336133446
Provider Name (Legal Business Name): RICHARD J MARTIN M.D., D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 SACHEM ST
NORWICH CT
06360-4144
US

IV. Provider business mailing address

159 SACHEM ST
NORWICH CT
06360-4144
US

V. Phone/Fax

Practice location:
  • Phone: 860-885-0444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number007905
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036472
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: