Provider Demographics
NPI:1477046944
Name:MARTIN, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5670 WILSHIRE BLVD STE 1700
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5626
Mailing Address - Country:US
Mailing Address - Phone:310-529-1127
Mailing Address - Fax:
Practice Address - Street 1:5670 WILSHIRE BLVD STE 1700
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-5626
Practice Address - Country:US
Practice Address - Phone:310-529-1127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1040181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice