Healthcare Provider Details

I. General information

NPI: 1982900908
Provider Name (Legal Business Name): PHILLIP RONALD MARTIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 S MARION AVE
LAKE CITY FL
32025-5855
US

IV. Provider business mailing address

844 S MARION AVE
LAKE CITY FL
32025-5855
US

V. Phone/Fax

Practice location:
  • Phone: 386-752-8531
  • Fax: 386-752-7681
Mailing address:
  • Phone: 386-752-8531
  • Fax: 386-752-7681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15702
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: