Provider Demographics
NPI:1154540227
Name:POWELL, MARTY MARION (DDS)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:MARION
Last Name:POWELL
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 1:5230 GRIGGS RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-3760
Mailing Address - Country:US
Mailing Address - Phone:313-657-5436
Mailing Address - Fax:
Practice Address - Street 1:14356 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2932
Practice Address - Country:US
Practice Address - Phone:313-824-9890
Practice Address - Fax:313-824-9894
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14298122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist