Provider Demographics
NPI:1972225068
Name:MARTENS, JEREMY RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:RICHARD
Last Name:MARTENS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 NE 3RD ST APT 196
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7813
Mailing Address - Country:US
Mailing Address - Phone:707-326-9465
Mailing Address - Fax:
Practice Address - Street 1:2004 SE 192ND AVE STE 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9526
Practice Address - Country:US
Practice Address - Phone:360-768-5609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA613227691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice