Provider Demographics
NPI:1720126683
Name:MARTINEZ, LETICIA (DDS)
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
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 1:3915 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3704
Mailing Address - Country:US
Mailing Address - Phone:773-522-2929
Mailing Address - Fax:
Practice Address - Street 1:3915 W 26TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3704
Practice Address - Country:US
Practice Address - Phone:773-522-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0270351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice