Provider Demographics
NPI:1902998164
Name:MARTIN, JEFF (DDS)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7228
Mailing Address - Country:US
Mailing Address - Phone:318-865-4091
Mailing Address - Fax:
Practice Address - Street 1:416 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7228
Practice Address - Country:US
Practice Address - Phone:318-865-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4720122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist