Healthcare Provider Details

I. General information

NPI: 1598507733
Provider Name (Legal Business Name): JAMES MARTINEZ DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 RIDGE AVE
PHILADELPHIA PA
19128-2446
US

IV. Provider business mailing address

1808 GINNODO ST
PHILADELPHIA PA
19130-1512
US

V. Phone/Fax

Practice location:
  • Phone: 215-483-6633
  • Fax:
Mailing address:
  • Phone: 302-367-6915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS044680
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: