Provider Demographics
NPI:1124267430
Name:MARTIN, DAN L (LAC, DOM)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LAC, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5323
Mailing Address - Country:US
Mailing Address - Phone:870-772-8622
Mailing Address - Fax:
Practice Address - Street 1:619 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5323
Practice Address - Country:US
Practice Address - Phone:870-772-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARDOM0002171100000X
DCNAT296175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath