Provider Demographics
NPI:1144261975
Name:MARTIN, EDDY DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:EDDY
Middle Name:DALE
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 1:3904 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3201
Mailing Address - Country:US
Mailing Address - Phone:817-238-6450
Mailing Address - Fax:817-238-6497
Practice Address - Street 1:3904 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3201
Practice Address - Country:US
Practice Address - Phone:817-238-6450
Practice Address - Fax:817-238-6497
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry