Basic Information
Provider Information | |||||||||
NPI: | 1982286860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANDERS | ||||||||
FirstName: | MARTIEZ | ||||||||
MiddleName: | OCTAVIUS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 203 S ROLLIE AVE | ||||||||
Address2: |   | ||||||||
City: | FORT LUPTON | ||||||||
State: | CO | ||||||||
PostalCode: | 806211508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3036972583 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 729 E RAILROAD AVE | ||||||||
Address2: |   | ||||||||
City: | FORT MORGAN | ||||||||
State: | CO | ||||||||
PostalCode: | 807013340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9704840999 | ||||||||
FaxNumber: | 9708672511 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2021 | ||||||||
LastUpdateDate: | 05/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 122300000X | DEN.00204944 | CO | Y |   | Dental Providers | Dentist |   |
No ID Information.