Provider Demographics
NPI:1427109875
Name:MARTIN, BRENT (DDS MBA)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1405
Mailing Address - Country:US
Mailing Address - Phone:860-561-0233
Mailing Address - Fax:860-561-0234
Practice Address - Street 1:1216 FARMINGTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2672
Practice Address - Country:US
Practice Address - Phone:860-561-4378
Practice Address - Fax:860-561-4384
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 82171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice