Provider Demographics
NPI:1306961487
Name:MARTIN, TIMOTHY ROSS (DDS)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ROSS
Last Name:MARTIN
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 1:1599 FORT HENRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664
Mailing Address - Country:US
Mailing Address - Phone:423-247-8172
Mailing Address - Fax:423-392-8253
Practice Address - Street 1:1599 FORT HENRY DRIVE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664
Practice Address - Country:US
Practice Address - Phone:423-247-8172
Practice Address - Fax:423-392-8253
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN25151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice