Provider Demographics
NPI:1629038625
Name:MARTIN, MICHELE G (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:G
Last Name:MARTIN
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 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 311
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5702
Mailing Address - Country:US
Mailing Address - Phone:323-653-7500
Mailing Address - Fax:
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:SUITE 311
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5702
Practice Address - Country:US
Practice Address - Phone:323-653-7500
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA383881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice