Provider Demographics
NPI:1417549486
Name:GUILLEN, MARTIN MARCOS
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:MARCOS
Last Name:GUILLEN
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 1:43243 33RD ST E
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4976
Mailing Address - Country:US
Mailing Address - Phone:661-718-6016
Mailing Address - Fax:
Practice Address - Street 1:1025 W AVENUE K STE 105
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6429
Practice Address - Country:US
Practice Address - Phone:310-409-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA66691Medicaid