Healthcare Provider Details

I. General information

NPI: 1093059123
Provider Name (Legal Business Name): MARTIN ROVIRA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AVOCADO AVE STE 404
NEWPORT BEACH CA
92660-7783
US

IV. Provider business mailing address

1401 AVOCADO AVE STE 404
NEWPORT BEACH CA
92660-7783
US

V. Phone/Fax

Practice location:
  • Phone: 949-640-1122
  • Fax:
Mailing address:
  • Phone: 949-640-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: