Healthcare Provider Details

I. General information

NPI: 1194146498
Provider Name (Legal Business Name): MARTINEZ DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2014
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W FOOTHILL BLVD
UPLAND CA
91786-3730
US

IV. Provider business mailing address

1060 W FOOTHILL BLVD
UPLAND CA
91786-3730
US

V. Phone/Fax

Practice location:
  • Phone: 909-373-4600
  • Fax: 909-373-4900
Mailing address:
  • Phone: 909-373-4600
  • Fax: 909-373-4900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41955
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JACKQUELINE M MARTINEZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 909-556-2820