Healthcare Provider Details

I. General information

NPI: 1326118613
Provider Name (Legal Business Name): TERESA L. MARTIN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4383 RHODES AVE
NEW BOSTON OH
45662-5532
US

IV. Provider business mailing address

4383 RHODES AVE
NEW BOSTON OH
45662-5532
US

V. Phone/Fax

Practice location:
  • Phone: 740-456-1100
  • Fax: 740-456-1036
Mailing address:
  • Phone: 740-456-1100
  • Fax: 740-456-1036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30020064
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: