Provider Demographics
NPI:1871152108
Name:MARTIN, TYESHA CHANEL (DDS)
Entity type:Individual
Prefix:
First Name:TYESHA
Middle Name:CHANEL
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 TALMADGE RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3539
Mailing Address - Country:US
Mailing Address - Phone:419-481-9762
Mailing Address - Fax:
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0261971223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program