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General NPI Number Information
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NPI Number | 1700578697
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Entity Type | Individual
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Provider Name | JACOB DAVID MARTIN DMD
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Gender | Male
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Dates
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Enumeration Date | 05/22/2023
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Last Update Date | 07/22/2024
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Provider Practice Location Address
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Address Line | 1851 COUNTY ROAD XX
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City | KRONENWETTER
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State | WI
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Zip | 54455-7933
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Country | US
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Telephone | 715-359-0550
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Fax |
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Provider Business Mailing Address
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Address Line | 820 GLADE CT APT 11
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City | KRONENWETTER
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State | WI
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Zip | 54455-7333
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Country | US
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Telephone | 423-710-6078
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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 | 6001570-15
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License Number State | WI
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