Healthcare Provider Details

I. General information

NPI: 1326744533
Provider Name (Legal Business Name): EDEYANIRA ALEXIS MARTINEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/14/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 ECHO RUN
IRVINE CA
92614-7423
US

IV. Provider business mailing address

41 ECHO RUN
IRVINE CA
92614-7423
US

V. Phone/Fax

Practice location:
  • Phone: 970-389-8591
  • Fax:
Mailing address:
  • Phone: 970-668-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.002024778
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: