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NPI Code Detail

MEDICARE: WALNUT AVENUE DENTISTRY

MEDICARE: WALNUT AVENUE DENTISTRY
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
1261QD0000XDental Clinic/Center

General Provider Information

NPI Number : 1801396403
Entity Type Code : Organization
Provider Name (Legal Business Name) : WALNUT AVENUE DENTISTRY
Provider Business Mailing Address
First Line : 305 WALNUT AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92103-4904
Country : US
Telephone Number : 619-291-1181
Fax Number :
Provider Business Practice Location Address
First Line : 305 WALNUT AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92103-4904
Country : US
Telephone Number : 619-291-1181
Fax Number :
Authorized Official
Title or Position : OWNER
Name : CHRISTIE LYNN MARTINEZ
Credential : DDS
Telephone Number : 619-291-1181
Provider Enumeration Date : 02/20/2018
Last Update Date : 02/20/2018

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Directions to “WALNUT AVENUE DENTISTRY ” Practice Location

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