Healthcare Provider Details

I. General information

NPI: 1831707736
Provider Name (Legal Business Name): TYLER E MARTINEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MORA VALLEY CLINIC RD
MORA NM
87732-2202
US

IV. Provider business mailing address

PO BOX 209
MORA NM
87732-0209
US

V. Phone/Fax

Practice location:
  • Phone: 505-387-2201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5299
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: