Healthcare Provider Details

I. General information

NPI: 1366524852
Provider Name (Legal Business Name): CHRIS ALAN MARTIN DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MED CENTER DRIVE
MORGANTOWN WV
26506
US

IV. Provider business mailing address

1 MED CENTER DRIVE
MORGANTOWN WV
26506
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-2240
  • Fax: 304-293-7646
Mailing address:
  • Phone: 304-293-2240
  • Fax: 304-293-7646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2469
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: