Healthcare Provider Details

I. General information

NPI: 1699127183
Provider Name (Legal Business Name): MARIO MARTINEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 8 AVE 6 APT 2
AGUA PRIETA SONORA
84200
MX

IV. Provider business mailing address

CALLE 8 AVE 6 APT 2
AGUA PRIETA SONORA
84200
MX

V. Phone/Fax

Practice location:
  • Phone: 520-505-7563
  • Fax:
Mailing address:
  • Phone: 520-505-7563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5234317
License Number StateZZ

VIII. Authorized Official

Name: MARIO MARTINEZ
Title or Position: OWNER
Credential: DDS
Phone: 520-505-7563