Provider Demographics
NPI:1851591705
Name:SOBIERAJ, MARTIN (DMD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:SOBIERAJ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E THOMAS RD
Mailing Address - Street 2:STE 204
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7675
Mailing Address - Country:US
Mailing Address - Phone:928-539-3082
Mailing Address - Fax:928-539-5579
Practice Address - Street 1:815 E JUAN SANCHEZ BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-2017
Practice Address - Country:US
Practice Address - Phone:928-627-8584
Practice Address - Fax:928-627-8949
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6664867-99211223G0001X
AZD73931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ232643Medicaid