Healthcare Provider Details

I. General information

NPI: 1881685725
Provider Name (Legal Business Name): GERALD THOMAS MARTIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 N MAIN ST
SHELBYVILLE TN
37160-2022
US

IV. Provider business mailing address

2012 N MAIN ST
SHELBYVILLE TN
37160-2022
US

V. Phone/Fax

Practice location:
  • Phone: 931-684-6351
  • Fax:
Mailing address:
  • Phone: 931-684-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1880
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: