Provider Demographics
NPI:1487849535
Name:MARTINEZ, LANISSA WAGNER (DDS)
Entity Type:Individual
Prefix:DR
First Name:LANISSA
Middle Name:WAGNER
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:BEEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78102-4048
Mailing Address - Country:US
Mailing Address - Phone:361-358-3384
Mailing Address - Fax:361-358-5199
Practice Address - Street 1:902 N SAINT MARYS ST
Practice Address - Street 2:
Practice Address - City:BEEVILLE
Practice Address - State:TX
Practice Address - Zip Code:78102-4048
Practice Address - Country:US
Practice Address - Phone:361-358-3384
Practice Address - Fax:361-358-5199
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice