Provider Demographics
NPI:1215056262
Name:MARTINEZ, JACKQUELINE M (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKQUELINE
Middle Name:M
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E 16TH ST
Mailing Address - Street 2:1
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-2401
Mailing Address - Country:US
Mailing Address - Phone:909-373-4600
Mailing Address - Fax:909-373-4900
Practice Address - Street 1:1225 E 16TH ST
Practice Address - Street 2:1
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-2401
Practice Address - Country:US
Practice Address - Phone:909-373-4600
Practice Address - Fax:909-373-4900
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist