Provider Demographics
NPI:1487046991
Name:MARTINO, IVAN A (DDS)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:A
Last Name:MARTINO
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 1:10347 77TH ST
Mailing Address - Street 2:SUITE 630
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1137
Mailing Address - Country:US
Mailing Address - Phone:262-694-6360
Mailing Address - Fax:
Practice Address - Street 1:10347 77TH ST
Practice Address - Street 2:SUITE 630
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1137
Practice Address - Country:US
Practice Address - Phone:262-694-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-21
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030078122300000X
WI1001205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist