Provider Demographics
NPI:1699388223
Name:MARTINEZ, IMELDA (RDA)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-4973
Mailing Address - Country:US
Mailing Address - Phone:310-820-9933
Mailing Address - Fax:
Practice Address - Street 1:1621 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-4973
Practice Address - Country:US
Practice Address - Phone:310-820-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75624126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant