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General NPI Number Information
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NPI Number | 1902884752
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Entity Type | Individual
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Provider Name | CHARISSA MICHELLE MARTIN DMD
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Gender | Female
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Dates
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Enumeration Date | 01/03/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 211 NORTH MAIN STREET
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City | BOULDER
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State | MT
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Zip | 59631
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Country | US
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Telephone | 406-225-4222
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Fax | 406-225-4222
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Provider Business Mailing Address
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Address Line | 211 NORTH MAIN STREET PO BOX 512
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City | BOULDER
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State | MT
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Zip | 59631
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Country | US
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Telephone | 406-225-4222
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Fax | 406-225-4222
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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 | 2386
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D8602
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License Number State | OR
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