Healthcare Provider Details

I. General information

NPI: 1447452636
Provider Name (Legal Business Name): WILLIAM BROCK MARTIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 23RD AVE
MERIDIAN MS
39301-4024
US

IV. Provider business mailing address

1411 23RD AVE
MERIDIAN MS
39301-4024
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-5701
  • Fax: 601-482-8401
Mailing address:
  • Phone: 601-485-5701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3396-06
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: