Healthcare Provider Details

I. General information

NPI: 1306908371
Provider Name (Legal Business Name): BRENT J MARTIN DDS MS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 W TOWNE SQUARE RD
MEQUON WI
53092-5047
US

IV. Provider business mailing address

1345 W TOWNE SQUARE RD
MEQUON WI
53092-5047
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-3019
  • Fax: 262-241-3027
Mailing address:
  • Phone: 262-241-3019
  • Fax: 262-241-3027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2529
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2529
License Number StateWI

VIII. Authorized Official

Name: DR. BRENT J MARTIN
Title or Position: ENDODONTIST ORAL AND MAXILLOFACIAL
Credential: DDS MS SC
Phone: 262-241-3019