MEDICARE: MARTINEZ DENTAL OFFICE

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	122300000X	Dentist	20546	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B20546-07	OTHER	CA	DENTI-CAL

General Provider Information

NPI Number	:	1477845113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTINEZ DENTAL OFFICE

Provider Business Mailing Address
First Line	:	2228 W 7TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4002
Country	:	US
Telephone Number	:	213-381-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2228 W 7TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-4002
Country	:	US
Telephone Number	:	213-381-7400
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	SPEED FRY
Credential	:
Telephone Number	:	213-381-7400

Provider Enumeration Date	:	05/13/2011
Last Update Date	:	05/13/2011

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Directions to “MARTINEZ DENTAL OFFICE ” Practice Location

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