Basic Information
| Provider Information | |||||||||
| NPI: | 1962514448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTINEZ-DIAZ | ||||||||
| OtherFirstName: | MIGUEL | ||||||||
| OtherMiddleName: | ANGEL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 505 N. PIEDRAS STREET | ||||||||
| Address2: | ATTN MS LAURA PORTER | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155685935 | ||||||||
| FaxNumber: | 9155685174 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N. PIEDRAS STREET | ||||||||
| Address2: | ATTN MS LAURA PORTER | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155685935 | ||||||||
| FaxNumber: | 9155685174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2713 | PR | N | Dental Providers | Dentist | 1223E0200X | 25427 | TX | Y | Dental Providers | Dentist | Endodontics |
No ID Information.