Provider Demographics
NPI:1093115537
Name:HATZKE, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:HATZKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5595 WINFIELD BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5595 WINFIELD BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1220
Practice Address - Country:US
Practice Address - Phone:408-224-1333
Practice Address - Fax:408-224-4192
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1669584355OtherNPI - ORGANIZATION