Charissa Michelle Martin, DMD
Individual provider Active NPI General Practice Dentistry · Boulder, MT
NPI 1902884752 · NPPES record last updated Mar 7, 2023
Key facts
- NPI
- 1902884752
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 2386 (MT)
- Practice address
- 211 North Main Street
Boulder, MT 59631 - Phone
- (406) 225-4222
- Fax
- (406) 225-4222
- NPI assigned
- Jan 3, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2386 | MT | MD | General Practice Dentistry |
| D8602 | OR | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Queen City Dental Studio, PLLC | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 2386 | MT | Yes |
| General Practice Dentistry | 1223G0001X | D8602 | OR |
Addresses
Primary practice location
211 North Main Street
Boulder, MT 59631
Mailing address
211 North Main Street
PO Box 512
Boulder, MT 59631
Phone (406) 225-4222
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 8098 | Other | NC | NC DENTAL LICENSE # |
| 5901637 | Medicaid | NC | |
| 9022M | Other | NC | BLUE CROSS BLUE SHIELD # |
Other providers in Boulder, MT
- Connie L Grenz
- Jefferson County Health Department
- Jonina Kenison
- Kristel Kishbaugh
- Jeni E Leary
- Clifford Josh Morris
- Cindy Ann Oliver
- Ellen Patricia Reynolds
- Sandra Kathleen Sample
- SCL Health Medical Group-Butte LLC
All providers in Boulder, MT · General Practice Dentistry in Montana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 7, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.