Provider Demographics
NPI:1033431630
Name:MARTIN, ELMEZEN OLIVERIO (RDHAP)
Entity type:Individual
Prefix:MRS
First Name:ELMEZEN
Middle Name:OLIVERIO
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 CRAIG AVE
Mailing Address - Street 2:P.O. BOX 23
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5704
Mailing Address - Country:US
Mailing Address - Phone:707-245-6859
Mailing Address - Fax:707-263-3625
Practice Address - Street 1:1281 CRAIG AVE
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5704
Practice Address - Country:US
Practice Address - Phone:707-245-6859
Practice Address - Fax:707-263-3625
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP281124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist