Healthcare Provider Details

I. General information

NPI: 1215033725
Provider Name (Legal Business Name): CLIFTON MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 ELM AVE
WACO TX
76704
US

IV. Provider business mailing address

1600 PROVIDENCE DR
WACO TX
76707-2261
US

V. Phone/Fax

Practice location:
  • Phone: 254-313-6960
  • Fax: 254-313-4531
Mailing address:
  • Phone: 254-313-4200
  • Fax: 254-313-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number14783
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: