Provider Demographics
NPI:1306908371
Name:BRENT J MARTIN DDS MS SC
Entity type:Organization
Organization Name:BRENT J MARTIN DDS MS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST ORAL AND MAXILLOFACIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS SC
Authorized Official - Phone:262-241-3019
Mailing Address - Street 1:1345 W TOWNE SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5047
Mailing Address - Country:US
Mailing Address - Phone:262-241-3019
Mailing Address - Fax:262-241-3027
Practice Address - Street 1:1345 W TOWNE SQUARE RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5047
Practice Address - Country:US
Practice Address - Phone:262-241-3019
Practice Address - Fax:262-241-3027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25291223S0112X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty