Provider Demographics
NPI:1689705782
Name:MARTINEZ, RICHARD DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DALE
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2936 HIGHLAND DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3583
Mailing Address - Country:US
Mailing Address - Phone:801-467-6555
Mailing Address - Fax:801-474-0103
Practice Address - Street 1:2936 HIGHLAND DR STE 101
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84106-3583
Practice Address - Country:US
Practice Address - Phone:801-467-6555
Practice Address - Fax:801-474-0103
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275081-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT115674Medicaid
793952OtherUNITED CONCORDIA
NM0018294Medicaid
NM87384051Medicaid
AKDD275UTMedicaid
CAG91893-01Medicaid
SD143256Medicaid
PA1017004720001Medicaid
AZ817463Medicaid