Healthcare Provider Details

I. General information

NPI: 1083786412
Provider Name (Legal Business Name): JOHN K MARTIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 BOULEVARD STE 102
TOCCOA GA
30577-3043
US

IV. Provider business mailing address

1975 BEVERLY RD
GAINESVILLE GA
30501-2034
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-4507
  • Fax: 706-282-4511
Mailing address:
  • Phone: 770-536-8871
  • Fax: 770-536-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7770
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: