Provider Demographics
NPI:1346567856
Name:SARASOLA, MICHELLE MARTINEZ (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARTINEZ
Last Name:SARASOLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 SW PORT ST. LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953
Mailing Address - Country:US
Mailing Address - Phone:772-871-9456
Mailing Address - Fax:772-871-9422
Practice Address - Street 1:3217 SW PORT ST. LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-871-9456
Practice Address - Fax:772-871-9422
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN184261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice