Provider Demographics
NPI:1235269457
Name:MARTINEZ, JUAN PEDRO (D D S)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:PEDRO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S INGLEWOOD AVE
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-8121
Mailing Address - Country:US
Mailing Address - Phone:310-674-3902
Mailing Address - Fax:310-674-4079
Practice Address - Street 1:1200 S INGLEWOOD AVE
Practice Address - Street 2:SUITE # 100
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-8121
Practice Address - Country:US
Practice Address - Phone:310-674-3902
Practice Address - Fax:310-674-4079
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD 36580Medicare ID - Type UnspecifiedDENTICAL