MEDICARE: MOONRIDGE MARTIN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1225864143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOONRIDGE MARTIN LLC

Provider Business Mailing Address
First Line	:	PO BOX 70887
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44190-0887
Country	:	US
Telephone Number	:	315-410-5531
Fax Number	:

Provider Business Practice Location Address
First Line	:	4356 N ORACLE RD STE 140
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85705-1634
Country	:	US
Telephone Number	:	315-410-5531
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, PAYOR STRATEGY
Name	:	VALERIE HAMILTON
Credential	:
Telephone Number	:	315-410-5531

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	09/09/2024

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Directions to “MOONRIDGE MARTIN LLC ” Practice Location

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