Provider Demographics
NPI:1093147266
Name:OTILIA MARTICORENA, DMD, PC
Entity Type:Organization
Organization Name:OTILIA MARTICORENA, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT- DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OTILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTICORENA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:908-355-8555
Mailing Address - Street 1:768 NEWARK AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3536
Mailing Address - Country:US
Mailing Address - Phone:908-355-8555
Mailing Address - Fax:908-355-8590
Practice Address - Street 1:768 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3536
Practice Address - Country:US
Practice Address - Phone:908-355-8555
Practice Address - Fax:908-355-8590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01915100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty