Healthcare Provider Details

I. General information

NPI: 1497276596
Provider Name (Legal Business Name): MATTHEW MARTINEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 PROSPECT PL NE
ALBUQUERQUE NM
87110-4313
US

IV. Provider business mailing address

76 VIA SEDILLO
TIJERAS NM
87059-7845
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-4548
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4696
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: