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General NPI Number Information
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NPI Number | 1558779918
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Entity Type | Organization
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Legal Business Name | M.D.M. OF ELLENTON P.A.
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Dates
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Enumeration Date | 07/30/2014
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Last Update Date | 07/30/2014
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Provider Practice Location Address
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Address Line | 5975 FACTORY SHOPS BLVD
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City | ELLENTON
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State | FL
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Zip | 34222-4125
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Country | US
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Telephone | 941-254-2300
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Fax |
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Provider Business Mailing Address
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Address Line | 701 S HOWARD AVE STE 106-386
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City | TAMPA
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State | FL
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Zip | 33606-2473
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY MARTIN
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Credential | DMD
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Telephone | 941-254-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN18829
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License Number State | FL
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