Healthcare Provider Details

I. General information

NPI: 1902813348
Provider Name (Legal Business Name): VERNON ARTHUR MARTIN L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 NE GLISAN ST
PORTLAND OR
97220-4456
US

IV. Provider business mailing address

21506 NE LACHENVIEW LN
FAIRVIEW OR
97024-9737
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-5959
  • Fax:
Mailing address:
  • Phone: 503-667-8053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number0516028598
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: