Healthcare Provider Details

I. General information

NPI: 1215166327
Provider Name (Legal Business Name): AMY MARTIN DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W WELLINGTON AVE
CHICAGO IL
60657-5123
US

IV. Provider business mailing address

811 W WELLINGTON AVE
CHICAGO IL
60657-5123
US

V. Phone/Fax

Practice location:
  • Phone: 773-871-4964
  • Fax:
Mailing address:
  • Phone: 773-871-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026201
License Number StateIL

VIII. Authorized Official

Name: DR. AMY R MARTIN
Title or Position: OWNER
Credential: DDS
Phone: 773-871-4964