Provider Demographics
NPI:1003363243
Name:MARTINEZ, JUAN GERARDO (DDS)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:GERARDO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:GERARDO
Other - Last Name:MARTINEZ ANAYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2919 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3723
Mailing Address - Country:US
Mailing Address - Phone:510-697-1029
Mailing Address - Fax:
Practice Address - Street 1:490 N MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92878-3461
Practice Address - Country:US
Practice Address - Phone:951-444-7010
Practice Address - Fax:951-444-7181
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1017811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program