Provider Demographics
NPI:1063565240
Name:MARTIN, CHRIS A (DDS)
Entity type:Individual
Prefix:
First Name:CHRIS
Middle Name:A
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:PO BOX 1050
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-1050
Mailing Address - Country:US
Mailing Address - Phone:707-937-1790
Mailing Address - Fax:707-937-6245
Practice Address - Street 1:45160 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460-1050
Practice Address - Country:US
Practice Address - Phone:707-937-1790
Practice Address - Fax:707-937-6245
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD421811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice