=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184265563
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALFREDO VELASCO MARTINEZ DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2019
-----------------------------------------------------
Last Update Date | 06/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3445 HENDERSON DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28546-5233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-347-1283
-----------------------------------------------------
Fax | 910-347-2153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | COMMANDING OFFICER 2D DENBN/NDC, PSC 20130 315 MCHUGH BLVD
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28542-0130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-451-2208
-----------------------------------------------------
Fax | 910-451-8479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 13316
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 104078
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------