Provider Demographics
NPI:1679785604
Name:MARTIN, BRANDON (DDS)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
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 1:201 SETTLERS TRACE BLVD
Mailing Address - Street 2:APT 3210
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1232 CAMELLIA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6973
Practice Address - Country:US
Practice Address - Phone:337-988-4060
Practice Address - Fax:337-988-4062
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2010-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice