Provider Demographics
NPI:1568081792
Name:MARTINEZ, MIGUEL A
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:MARTINEZ
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 1:3308 GREENOCK ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-4100
Mailing Address - Country:US
Mailing Address - Phone:915-820-4803
Mailing Address - Fax:
Practice Address - Street 1:3308 GREENOCK ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-4100
Practice Address - Country:US
Practice Address - Phone:915-820-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19381124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist