Basic Information
Provider Information | |||||||||
NPI: | 1144634577 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTINEAU | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | HENRY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 389 192ND ARMORED TANK BATTALION ROAD | ||||||||
Address2: | BUILDING 1022, ROOM 231 | ||||||||
City: | FORT KNOX | ||||||||
State: | KY | ||||||||
PostalCode: | 401215116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026246158 | ||||||||
FaxNumber: | 5026624296 | ||||||||
Practice Location | |||||||||
Address1: | 968 1ST INFANTRY DIVISION ROAD | ||||||||
Address2: | JORDAN DENTAL CLINIC (BLDG 2724 | ||||||||
City: | FORT KNOX | ||||||||
State: | KY | ||||||||
PostalCode: | 40121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5026268301 | ||||||||
FaxNumber: | 5026242966 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2014 | ||||||||
LastUpdateDate: | 06/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12012139A | IN | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.