Provider Demographics
NPI:1639390396
Name:MARTINEZ, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10405 E NORTHWEST HWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-4619
Mailing Address - Country:US
Mailing Address - Phone:214-343-2331
Mailing Address - Fax:214-343-0515
Practice Address - Street 1:10405 E NORTHWEST HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-4619
Practice Address - Country:US
Practice Address - Phone:214-343-2331
Practice Address - Fax:214-343-0515
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10188124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist