=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558435537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDMUNDO MARTINEZ DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 N CHURCH ST STE 206
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-1448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-378-9433
-----------------------------------------------------
Fax | 336-378-9796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4907 SETTER CT
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27282-8655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-323-1499
-----------------------------------------------------
Fax | 336-378-9796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 6414
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------