Healthcare Provider Details

I. General information

NPI: 1366552440
Provider Name (Legal Business Name): DARYL JOHNATHON MARTIN JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN MARTIN DDS

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11705 DORSETT RD STE 205
MARYLAND HEIGHTS MO
63043-2517
US

IV. Provider business mailing address

11705 DORSETT RD STE 205
MARYLAND HEIGHTS MO
63043-2517
US

V. Phone/Fax

Practice location:
  • Phone: 314-739-1222
  • Fax: 314-739-1094
Mailing address:
  • Phone: 314-739-1222
  • Fax: 314-739-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: