Provider Demographics
NPI:1225232101
Name:SPANISH, MARTY MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:MICHAEL
Last Name:SPANISH
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 1:800 MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-2055
Mailing Address - Country:US
Mailing Address - Phone:651-451-1277
Mailing Address - Fax:651-451-0061
Practice Address - Street 1:800 MARIE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-2055
Practice Address - Country:US
Practice Address - Phone:651-451-1277
Practice Address - Fax:651-451-0061
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12417122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist