Provider Demographics
NPI:1578697066
Name:MERCEDES MOTA-MARTINEZ, DENTIST, PC
Entity Type:Organization
Organization Name:MERCEDES MOTA-MARTINEZ, DENTIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTA-MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-779-2214
Mailing Address - Street 1:10401 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2327
Mailing Address - Country:US
Mailing Address - Phone:718-779-2214
Mailing Address - Fax:
Practice Address - Street 1:10401 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2327
Practice Address - Country:US
Practice Address - Phone:718-779-2214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0405401223G0001X
NY0437101223G0001X
NY0476411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01869956Medicaid
NY00998187Medicaid
NY01268620Medicaid