Healthcare Provider Details

I. General information

NPI: 1104147768
Provider Name (Legal Business Name): VANESSA R MARTIN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S JEFFERSON ST
LANCASTER WI
53813-1666
US

IV. Provider business mailing address

111 S JEFFERSON ST
LANCASTER WI
53813-1666
US

V. Phone/Fax

Practice location:
  • Phone: 608-723-6416
  • Fax: 608-723-6501
Mailing address:
  • Phone: 608-723-6416
  • Fax: 608-723-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10572-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: