Provider Demographics
NPI:1992161012
Name:DUSTIN MARTINEZ DC
Entity type:Organization
Organization Name:DUSTIN MARTINEZ DC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OMD LAC
Authorized Official - Phone:310-547-2197
Mailing Address - Street 1:1366 W 7TH ST
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3500
Mailing Address - Country:US
Mailing Address - Phone:310-547-2197
Mailing Address - Fax:310-547-9532
Practice Address - Street 1:1366 W 7TH ST
Practice Address - Street 2:SUITE 4B
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3500
Practice Address - Country:US
Practice Address - Phone:310-547-2197
Practice Address - Fax:310-547-9532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN PEDRO HEALING ARTS MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-05
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC33346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC33346OtherCHIROPRACTOR LICENSE