Basic Information
| Provider Information | |||||||||
| NPI: | 1356914055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MARIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5043 BOUGAINVILLEA DR | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951113906 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 351 FELICE DR | ||||||||
| Address2: | |||||||||
| City: | HOLLISTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950233361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316375306 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2021 | ||||||||
| LastUpdateDate: | 07/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 106653 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.