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General NPI Number Information
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NPI Number | 1568670537
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Entity Type | Organization
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Legal Business Name | FORT THEATRE DENTISTRY
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 2205 CENTRAL AVE
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City | KEARNEY
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State | NE
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Zip | 68847-5346
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Country | US
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Telephone | 308-237-5853
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Fax | 308-237-5089
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Provider Business Mailing Address
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Address Line | 2205 CENTRAL AVE
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City | KEARNEY
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State | NE
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Zip | 68847-5346
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Country | US
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Telephone | 308-237-5853
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Fax | 308-237-5089
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Authorized Official
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Title or Position | OWNER
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Name | DR. WALTER D MARTIN
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Credential | DMD
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Telephone | 308-237-5853
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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