Provider Demographics
NPI:1639254295
Name:MARTINEZ PHAM, MICHELLE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MARTINEZ PHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:545 MARKS ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6500
Mailing Address - Country:US
Mailing Address - Phone:702-425-3697
Mailing Address - Fax:702-450-6539
Practice Address - Street 1:545 MARKS ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6500
Practice Address - Country:US
Practice Address - Phone:702-425-3697
Practice Address - Fax:702-450-6539
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45733122300000X
NV50041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist