Provider Demographics
NPI:1386898963
Name:MARTZ, MARTIN G (DDS, MS,)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:G
Last Name:MARTZ
Suffix:
Gender:M
Credentials:DDS, MS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVE.
Mailing Address - Street 2:UCLA DEPARTMENT OF ORTHODONTICS MD 12-334
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1752
Mailing Address - Country:US
Mailing Address - Phone:310-825-5651
Mailing Address - Fax:310-206-4921
Practice Address - Street 1:10833 LE CONTE AVE.
Practice Address - Street 2:UCLA DEPARTMENT OF ORTHODONTICS MD 12-334
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1752
Practice Address - Country:US
Practice Address - Phone:310-825-5161
Practice Address - Fax:310-206-4921
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA262031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP163017Medicaid