=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780955047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FERMIN MARTIN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2012
-----------------------------------------------------
Last Update Date | 01/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARRETERA AEROPUERTO #1900 LOCAL E-21
-----------------------------------------------------
City | TIJUANA
-----------------------------------------------------
State | BAJA CALIFORNIA NORTE
-----------------------------------------------------
Zip | 22457
-----------------------------------------------------
Country | MX
-----------------------------------------------------
Telephone | 664-647-9026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2475 PASEO DE LAS AMERICAS STE 1781
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92154-7255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-600-5183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 4118736
-----------------------------------------------------
License Number State | ZZ
-----------------------------------------------------