MEDICARE: DR. JASON ELLIS MARTIN DDS

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	1223G0001X	General Practice Dentistry	8173	NC

General Provider Information

NPI Number	:	1619073533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON ELLIS MARTIN DDS

Provider Business Mailing Address
First Line	:	236 MARKET ST
Second Line	:	SUITE 200
City	:	LOCUST
State	:	NC
Zip	:	28097-9438
Country	:	US
Telephone Number	:	704-781-0500
Fax Number	:	704-781-0555

Provider Business Practice Location Address
First Line	:	236 MARKET ST
Second Line	:	SUITE 200
City	:	LOCUST
State	:	NC
Zip	:	28097-9438
Country	:	US
Telephone Number	:	704-781-0500
Fax Number	:	704-781-0555

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	01/23/2013

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