Provider Demographics
NPI:1588928006
Name:MARTIN, CLINT (DMD)
Entity type:Individual
Prefix:DR
First Name:CLINT
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 E KNOXVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BRIMFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61517-8103
Mailing Address - Country:US
Mailing Address - Phone:309-396-3123
Mailing Address - Fax:
Practice Address - Street 1:232 E KNOXVILLE ST
Practice Address - Street 2:
Practice Address - City:BRIMFIELD
Practice Address - State:IL
Practice Address - Zip Code:61517-8103
Practice Address - Country:US
Practice Address - Phone:309-320-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029025122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist