Provider Demographics
NPI:1720312143
Name:MARTINEZ, MIGUEL ANGEL
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18355 STALLION LN
Mailing Address - Street 2:18355 STALLION LN
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-3142
Mailing Address - Country:US
Mailing Address - Phone:909-644-2531
Mailing Address - Fax:
Practice Address - Street 1:18355 STALLION LN
Practice Address - Street 2:18355 STALLION LN
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-3142
Practice Address - Country:US
Practice Address - Phone:909-644-2531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA460325126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA460325OtherDA CERIFICATE