Provider Demographics
NPI:1225318124
Name:PUGA, MARTIN F
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:F
Last Name:PUGA
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 1:3221 NAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-4800
Mailing Address - Country:US
Mailing Address - Phone:619-207-2532
Mailing Address - Fax:
Practice Address - Street 1:ROSARIO CASTELLANOS # 10160 7B
Practice Address - Street 2:ZONA RIO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORINA
Practice Address - Zip Code:22300
Practice Address - Country:MX
Practice Address - Phone:619-861-4782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ2312763 MEXICO1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice