Provider Demographics
NPI:1487385217
Name:MARTINEZ REYNA, PERLA IVETH
Entity type:Individual
Prefix:
First Name:PERLA
Middle Name:IVETH
Last Name:MARTINEZ REYNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11424 FLOR LIATRIS
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927
Mailing Address - Country:US
Mailing Address - Phone:915-215-9491
Mailing Address - Fax:915-233-5301
Practice Address - Street 1:AV TECNOLOGICO #1337-B
Practice Address - Street 2:
Practice Address - City:CD.JUAREZ
Practice Address - State:CHIHUAHUA
Practice Address - Zip Code:32310
Practice Address - Country:MX
Practice Address - Phone:656-341-7541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ091541011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice