Healthcare Provider Details

I. General information

NPI: 1124879093
Provider Name (Legal Business Name): DR. ANDRES RUDOLFO MARTINEZ II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 23RD AVE
MELROSE PARK IL
60160-3635
US

IV. Provider business mailing address

134 N 23RD AVE
MELROSE PARK IL
60160-3635
US

V. Phone/Fax

Practice location:
  • Phone: 708-769-2224
  • Fax:
Mailing address:
  • Phone: 708-769-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number019035232
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: