MEDICARE: BRENT J MARTIN DDS MS SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2529	WI
2	1223E0200X	Endodontics	2529	WI

General Provider Information

NPI Number	:	1306908371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENT J MARTIN DDS MS SC

Provider Business Mailing Address
First Line	:	1345 W TOWNE SQUARE RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5047
Country	:	US
Telephone Number	:	262-241-3019
Fax Number	:	262-241-3027

Provider Business Practice Location Address
First Line	:	1345 W TOWNE SQUARE RD
Second Line	:
City	:	MEQUON
State	:	WI
Zip	:	53092-5047
Country	:	US
Telephone Number	:	262-241-3019
Fax Number	:	262-241-3027

Authorized Official
Title or Position	:	ENDODONTIST ORAL AND MAXILLOFACIAL
Name	:	DR. BRENT J MARTIN
Credential	:	DDS MS SC
Telephone Number	:	262-241-3019

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	04/24/2012

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