Provider Demographics
NPI:1073023560
Name:MARTIN, RAYSA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYSA
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WYCKOFF AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1525
Mailing Address - Country:US
Mailing Address - Phone:201-891-4425
Mailing Address - Fax:201-891-7926
Practice Address - Street 1:800 WYCKOFF AVE STE 101
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1525
Practice Address - Country:US
Practice Address - Phone:201-891-4425
Practice Address - Fax:201-891-7926
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02691900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist