Healthcare Provider Details

I. General information

NPI: 1093147266
Provider Name (Legal Business Name): OTILIA MARTICORENA, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

768 NEWARK AVE
ELIZABETH NJ
07208-3536
US

IV. Provider business mailing address

768 NEWARK AVE
ELIZABETH NJ
07208-3536
US

V. Phone/Fax

Practice location:
  • Phone: 908-355-8555
  • Fax: 908-355-8590
Mailing address:
  • Phone: 908-355-8555
  • Fax: 908-355-8590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI01915100
License Number StateNJ

VIII. Authorized Official

Name: DR. OTILIA MARTICORENA
Title or Position: PRESIDENT- DENTIST
Credential: DMD
Phone: 908-355-8555