Healthcare Provider Details

I. General information

NPI: 1154819043
Provider Name (Legal Business Name): DR. ALAN J MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 HERBERT ST
ST AUGUSTINE FL
32084-4000
US

IV. Provider business mailing address

690 WILD CYPRESS CIR
PONTE VEDRA BEACH FL
32081-5731
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-1962
  • Fax:
Mailing address:
  • Phone: 904-829-1962
  • Fax: 904-395-3489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN23010
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: