Healthcare Provider Details

I. General information

NPI: 1619990892
Provider Name (Legal Business Name): CLIFFORD LEE MARTIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N WEINBACH AVE SUITE 920
EVANSVILLE IN
47711
US

IV. Provider business mailing address

701 N WEINBACH AVE SUITE 920
EVANSVILLE IN
47711
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-8949
  • Fax: 812-477-3945
Mailing address:
  • Phone: 812-477-8949
  • Fax: 812-477-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12009674
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: