Healthcare Provider Details

I. General information

NPI: 1982811758
Provider Name (Legal Business Name): MICHAEL M MARTIN DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL M MARTIN DDS,MS

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 E BARNETT RD
MEDFORD OR
97504-8309
US

IV. Provider business mailing address

2930 E BARNETT RD
MEDFORD OR
97504-8309
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-4501
  • Fax: 541-779-8674
Mailing address:
  • Phone: 541-779-4501
  • Fax: 541-779-8674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD8721
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: