Provider Demographics
NPI:1467460261
Name:MARTIN, MICHAEL RAY (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 CERRILLOS RD
Mailing Address - Street 2:STE 507
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-438-0756
Mailing Address - Fax:505-424-7933
Practice Address - Street 1:3600 CERRILLOS RD
Practice Address - Street 2:STE 507
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-438-0756
Practice Address - Fax:505-424-7933
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice