Provider Demographics
NPI:1447452636
Name:MARTIN, WILLIAM BROCK (DMD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BROCK
Last Name:MARTIN
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 1:1411 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4024
Mailing Address - Country:US
Mailing Address - Phone:601-485-5701
Mailing Address - Fax:
Practice Address - Street 1:1411 23RD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4024
Practice Address - Country:US
Practice Address - Phone:601-482-5701
Practice Address - Fax:601-482-8401
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3396-06122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3396-06OtherSTATE LICENSE NUMBER