Provider Demographics
NPI:1619424066
Name:MUTIS, MARTHA JEANNETHE (DMD MPH)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:JEANNETHE
Last Name:MUTIS
Suffix:
Gender:F
Credentials:DMD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 MAIN ST APT 7
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-7128
Mailing Address - Country:US
Mailing Address - Phone:914-740-4199
Mailing Address - Fax:
Practice Address - Street 1:5800 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3702
Practice Address - Country:US
Practice Address - Phone:718-630-7152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program