Healthcare Provider Details

I. General information

NPI: 1467525923
Provider Name (Legal Business Name): MARTIN L DONALDSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 UNION AVE RM S219
MEMPHIS TN
38163-0001
US

IV. Provider business mailing address

875 UNION AVE RM S219
MEMPHIS TN
38163-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-4944
  • Fax: 901-448-7104
Mailing address:
  • Phone: 901-448-4944
  • Fax: 901-448-7104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS0000008143
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: