Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DN 15205 | FL |
NPI | 1093925133 |
---|---|
Provider Name | Mario Jose Martinez |
First Address | South Miami, FL 33143-4661 |
Second Address | South Miami, FL 33143-4661 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2007 |
Last Update Date | 08/07/2007 |