=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205969722
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW J. MARTINEAU DMD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 01/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 943 S BENEVA RD SUITE #310
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34232-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-957-3703
-----------------------------------------------------
Fax | 941-955-5270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 943 S BENEVA RD SUITE #310
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34232-2476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-957-3703
-----------------------------------------------------
Fax | 941-955-5270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. ANDREW J MARTINEAU
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 941-957-3703
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN12356
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------