Provider Demographics
NPI:1003088006
Name:MARTINEZ DENTAL PC
Entity Type:Organization
Organization Name:MARTINEZ DENTAL PC
Other - Org Name:UNIVERSAL DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-522-2929
Mailing Address - Street 1:3915 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623
Mailing Address - Country:US
Mailing Address - Phone:773-522-2929
Mailing Address - Fax:773-522-2930
Practice Address - Street 1:3915 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623
Practice Address - Country:US
Practice Address - Phone:773-522-2929
Practice Address - Fax:773-522-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190270351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty