Provider Demographics
NPI:1386079465
Name:MARTINEZ, BERNICE (RDH)
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 ALTADENA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2963
Mailing Address - Country:US
Mailing Address - Phone:719-566-0445
Mailing Address - Fax:
Practice Address - Street 1:1700 N SALEM AVE STE B
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-2846
Practice Address - Country:US
Practice Address - Phone:719-582-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODH000905418124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist