MEDICARE: MR. MICHAEL RAY MARTIN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1488	NM

General Provider Information

NPI Number	:	1467460261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL RAY MARTIN DDS

Provider Business Mailing Address
First Line	:	3600 CERRILLOS RD
Second Line	:	STE 507
City	:	SANTA FE
State	:	NM
Zip	:	87507
Country	:	US
Telephone Number	:	505-438-0756
Fax Number	:	505-424-7933

Provider Business Practice Location Address
First Line	:	3600 CERRILLOS RD
Second Line	:	STE 507
City	:	SANTA FE
State	:	NM
Zip	:	87507
Country	:	US
Telephone Number	:	505-438-0756
Fax Number	:	505-424-7933

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/08/2007

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