Provider Demographics
NPI:1982286860
Name:SANDERS, MARTIEZ OCTAVIUS (DDS)
Entity Type:Individual
Prefix:
First Name:MARTIEZ
Middle Name:OCTAVIUS
Last Name:SANDERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-697-2583
Mailing Address - Fax:
Practice Address - Street 1:729 E RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3340
Practice Address - Country:US
Practice Address - Phone:970-484-0999
Practice Address - Fax:970-867-2511
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.00204944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program