Provider Demographics
NPI:1104147768
Name:MARTIN, VANESSA R (RDH)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-1666
Mailing Address - Country:US
Mailing Address - Phone:608-723-6416
Mailing Address - Fax:608-723-6501
Practice Address - Street 1:111 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-1666
Practice Address - Country:US
Practice Address - Phone:608-723-6416
Practice Address - Fax:608-723-6501
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10572-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist