Healthcare Provider Details

I. General information

NPI: 1760810444
Provider Name (Legal Business Name): MARTIN, DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 7TH AVE
SOUTH CHARLESTOWN WV
25303
US

IV. Provider business mailing address

140 7TH AVE
SOUTH CHARLESTOWN WV
25303
US

V. Phone/Fax

Practice location:
  • Phone: 304-342-4422
  • Fax: 304-400-4986
Mailing address:
  • Phone: 304-342-4422
  • Fax: 304-400-4986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3945
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3827
License Number StateWV

VIII. Authorized Official

Name: MR. JARREL R MARTIN II
Title or Position: MEMBER/OWNER
Credential: DDS
Phone: 304-419-0125