Healthcare Provider Details

I. General information

NPI: 1609585835
Provider Name (Legal Business Name): MARTIN DUARTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PIERSON 86 D AVE OBREGON
NOGALES SONORA
84030
MX

IV. Provider business mailing address

2275 N CALLE RIVAS
NOGALES AZ
85621-3371
US

V. Phone/Fax

Practice location:
  • Phone: 631-102-2012
  • Fax: 619-329-9663
Mailing address:
  • Phone: 631-102-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARTIN DUARTE
Title or Position: DENTIST
Credential: DDS
Phone: 631-102-2012