Healthcare Provider Details

I. General information

NPI: 1336571611
Provider Name (Legal Business Name): MARTIN KIDS DENTAL HEALTH TEAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13820 W NEWBERRY RD STE 100
JONESVILLE FL
32669
US

IV. Provider business mailing address

13820 W NEWBERRY RD STE 100
JONESVILLE FL
32669-2093
US

V. Phone/Fax

Practice location:
  • Phone: 352-371-3200
  • Fax: 352-377-7102
Mailing address:
  • Phone: 352-371-3200
  • Fax: 352-377-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number19462
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN7298
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number20184
License Number StateFL

VIII. Authorized Official

Name: WILLIAM B MARTIN
Title or Position: OWNER
Credential:
Phone: 352-371-3200