Provider Demographics
NPI:1063582732
Name:MARTINOLAS, CARLOS A (DDS)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:MARTINOLAS
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 1:11349 TARA BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6261
Mailing Address - Country:US
Mailing Address - Phone:770-472-4415
Mailing Address - Fax:770-472-4590
Practice Address - Street 1:11349 TARA BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6261
Practice Address - Country:US
Practice Address - Phone:770-472-4415
Practice Address - Fax:770-472-4590
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012501122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA351027353HMedicaid