=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376722991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTAGUE L MARTIN DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2007
-----------------------------------------------------
Last Update Date | 10/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12650 WARWICK BLVD
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-2521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-930-4800
-----------------------------------------------------
Fax | 757-930-8300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12650 WARWICK BLVD
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23606-2521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-930-4800
-----------------------------------------------------
Fax | 757-930-8300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MONTAGUE L MARTIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 757-930-4800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401003137
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------