Healthcare Provider Details

I. General information

NPI: 1740943745
Provider Name (Legal Business Name): ANTONIO MARTINEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2021
Last Update Date: 10/16/2021
Certification Date: 10/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLVD BENITO JUAREZ 22710
ROSARITO BAJA CALIFORNIA
22710
MX

IV. Provider business mailing address

2013 DAIRY MART RD UNIT 3
SAN YSIDRO CA
92173-1848
US

V. Phone/Fax

Practice location:
  • Phone: 619-209-8924
  • Fax:
Mailing address:
  • Phone: 619-209-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: HECTOR G MORALES
Title or Position: DENTAL INSURANCE CLAIMS DEPARTMENT
Credential:
Phone: 619-209-8924