Provider Demographics
NPI:1093459232
Name:MARTIN, JEANNY TEJEDA
Entity type:Individual
Prefix:
First Name:JEANNY
Middle Name:TEJEDA
Last Name:MARTIN
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 1:2801 SUNSET PL APT 1407
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-4482
Mailing Address - Country:US
Mailing Address - Phone:857-492-4099
Mailing Address - Fax:
Practice Address - Street 1:2800 W MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3036
Practice Address - Country:US
Practice Address - Phone:818-846-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2024-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1086311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice