Provider Demographics
NPI:1811510720
Name:MARTINEZ, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8523 BLANCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3901
Mailing Address - Country:US
Mailing Address - Phone:909-749-2422
Mailing Address - Fax:
Practice Address - Street 1:9745 LAUREL CANYON BLVD STE A
Practice Address - Street 2:
Practice Address - City:ARLETA
Practice Address - State:CA
Practice Address - Zip Code:91331-4115
Practice Address - Country:US
Practice Address - Phone:818-435-3106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81162126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81162Medicaid