Provider Demographics
NPI:1265051999
Name:MARTINEZ, AMANDA LEE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:ZOLCAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 W NAVAJO ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-1999
Mailing Address - Country:US
Mailing Address - Phone:765-463-5437
Mailing Address - Fax:
Practice Address - Street 1:520 W NAVAJO ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1999
Practice Address - Country:US
Practice Address - Phone:765-463-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013374A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300038906Medicaid