Healthcare Provider Details

I. General information

NPI: 1962563239
Provider Name (Legal Business Name): TU-WANDA MARABLE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S PLEASANTBURG DR E10
GREENVILLE SC
29607-2544
US

IV. Provider business mailing address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

V. Phone/Fax

Practice location:
  • Phone: 864-233-7737
  • Fax:
Mailing address:
  • Phone: 719-583-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number687
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: