Healthcare Provider Details

I. General information

NPI: 1003363243
Provider Name (Legal Business Name): JUAN GERARDO MARTINEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN GERARDO MARTINEZ ANAYA DDS

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 10/19/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 N MAIN ST STE 207
CORONA CA
92878-3461
US

IV. Provider business mailing address

2919 WILLOW RD
SAN PABLO CA
94806-3723
US

V. Phone/Fax

Practice location:
  • Phone: 951-444-7010
  • Fax: 951-444-7181
Mailing address:
  • Phone: 510-697-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS101781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: