Healthcare Provider Details

I. General information

NPI: 1639371750
Provider Name (Legal Business Name): ERIC MARTIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3254 DEER HOLLOW DR
SANDY UT
84092-6506
US

IV. Provider business mailing address

3254 DEER HOLLOW DR
SANDY UT
84092-6506
US

V. Phone/Fax

Practice location:
  • Phone: 801-419-9451
  • Fax:
Mailing address:
  • Phone: 801-419-9451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4955444-8903
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: