Healthcare Provider Details

I. General information

NPI: 1730176157
Provider Name (Legal Business Name): MYRA VALDEZ MARTIN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS THEODORE ROOSEVELT
FPO AP
09599-2871
US

IV. Provider business mailing address

1322 CLUB HOUSE DR
CHESAPEAKE VA
23322-8073
US

V. Phone/Fax

Practice location:
  • Phone: 757-444-5987
  • Fax:
Mailing address:
  • Phone: 757-410-9681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19026326
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: