MEDICARE: MARTIN SMALLIDGE DMD

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	DS040045	PA
2	1223P0700X	Prosthodontics	DS040045	PA

General Provider Information

NPI Number	:	1992113062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN SMALLIDGE DMD

Provider Business Mailing Address
First Line	:	2450 CONNELL RD
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7664
Country	:	US
Telephone Number	:	210-466-5597
Fax Number	:

Provider Business Practice Location Address
First Line	:	3145 GARDEN AVE
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7718
Country	:	US
Telephone Number	:	210-808-3737
Fax Number	:

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

Provider Enumeration Date	:	08/01/2014
Last Update Date	:	07/05/2023

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Directions to “ MARTIN SMALLIDGE DMD” Practice Location

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