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General NPI Number Information
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NPI Number | 1275742280
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Entity Type | Individual
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Provider Name | GABRIEL WILEY MARTIN D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 130 THOMPSON ST
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City | ASHLAND
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State | VA
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Zip | 23005-1526
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Country | US
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Telephone | 804-798-2776
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Fax | 804-798-3110
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Provider Business Mailing Address
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Address Line | 1621 CHARLES ST
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City | RICHMOND
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State | VA
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Zip | 23226-3502
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Country | US
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Telephone | 804-337-4146
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401411475
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License Number State | VA
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