Healthcare Provider Details

I. General information

NPI: 1326126673
Provider Name (Legal Business Name): GARY DEWAYNE MARTIN JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14444 DALLAS PKWY SUITE 115
DALLAS TX
75254-8304
US

IV. Provider business mailing address

14444 DALLAS PKWY SUITE 115
DALLAS TX
75254-8304
US

V. Phone/Fax

Practice location:
  • Phone: 972-789-1234
  • Fax: 972-789-1589
Mailing address:
  • Phone: 972-789-1234
  • Fax: 972-789-1589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number6457
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: