Provider Demographics
NPI:1831558964
Name:MARTINEZ, GUSTAVO A
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3559 S FEDERAL HWY APT D
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-8696
Mailing Address - Country:US
Mailing Address - Phone:786-389-1709
Mailing Address - Fax:
Practice Address - Street 1:3559 S FEDERAL HWY APT D
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-8696
Practice Address - Country:US
Practice Address - Phone:786-389-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist