Healthcare Provider Details

I. General information

NPI: 1578600359
Provider Name (Legal Business Name): JOHN C. MARTIN D.M.D., M.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PEARL NIX PKWY SUITE E
GAINESVILLE GA
30501-4101
US

IV. Provider business mailing address

300 PEARL NIX PKWY SUITE E
GAINESVILLE GA
30501-4101
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-5535
  • Fax: 770-535-5540
Mailing address:
  • Phone: 770-535-5535
  • Fax: 770-535-5540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number008367
License Number StateGA

VIII. Authorized Official

Name: JOHN C MARTIN
Title or Position: ORTHODONTIST
Credential: D.M.D., M.S.
Phone: 770-535-5535