Provider Demographics
NPI:1871861179
Name:LEYBA MARTINEZ, LORI (RDH)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LEYBA MARTINEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:538 N. PASEO DE ONATE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-747-7396
Practice Address - Street 1:608 LA JOYA ST STE B
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3467
Practice Address - Country:US
Practice Address - Phone:505-753-9454
Practice Address - Fax:505-753-0850
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3203124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist