Basic Information
| Provider Information | |||||||||
| NPI: | 1003155011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 S DENTON TAP RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750195038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013185003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 S DENTON TAP RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750195038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723935550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2013 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 29865 | TX | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.