MEDICARE: AQUILEO MARTINEZ D.D.S., INC.

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	42362	CA

General Provider Information

NPI Number	:	1295867414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUILEO MARTINEZ D.D.S., INC.

Provider Business Mailing Address
First Line	:	4521 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-2407
Country	:	US
Telephone Number	:	323-261-4838
Fax Number	:	323-261-6399

Provider Business Practice Location Address
First Line	:	4521 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-2407
Country	:	US
Telephone Number	:	323-261-4838
Fax Number	:	323-261-6399

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AQUILEO MARTINEZ DE LA CRUZ
Credential	:	D.D.S.
Telephone Number	:	323-261-4838

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	06/21/2012

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