Healthcare Provider Details

I. General information

NPI: 1649623307
Provider Name (Legal Business Name): STEPHEN JOSEPH MARTIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 DEMPSTER ST
SKOKIE IL
60076-2008
US

IV. Provider business mailing address

801 LOCUST ST
WINNETKA IL
60093-1821
US

V. Phone/Fax

Practice location:
  • Phone: 404-788-8520
  • Fax:
Mailing address:
  • Phone: 404-788-8520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019.030873
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: