Provider Demographics
NPI:1730441270
Name:NOLAN, MARTHA JENNILEE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:JENNILEE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5454 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7508
Mailing Address - Country:US
Mailing Address - Phone:318-396-0054
Mailing Address - Fax:318-397-0850
Practice Address - Street 1:5454 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7508
Practice Address - Country:US
Practice Address - Phone:318-396-0054
Practice Address - Fax:318-397-0850
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA62621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1862622Medicaid