Provider Demographics
NPI:1699127183
Name:MARIO MARTINEZ
Entity type:Organization
Organization Name:MARIO MARTINEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-505-7563
Mailing Address - Street 1:CALLE 8 AVE 6
Mailing Address - Street 2:APT 2
Mailing Address - City:AGUA PRIETA
Mailing Address - State:SONORA
Mailing Address - Zip Code:84200
Mailing Address - Country:MX
Mailing Address - Phone:520-505-7563
Mailing Address - Fax:
Practice Address - Street 1:CALLE 8 AVE 6
Practice Address - Street 2:APT 2
Practice Address - City:AGUA PRIETA
Practice Address - State:SONORA
Practice Address - Zip Code:84200
Practice Address - Country:MX
Practice Address - Phone:520-505-7563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ5234317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty