Provider Demographics
NPI:1679274260
Name:MARTINO, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:MARTINO
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 1:16008 88TH ST
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3038
Mailing Address - Country:US
Mailing Address - Phone:718-744-4122
Mailing Address - Fax:
Practice Address - Street 1:785 W MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8219
Practice Address - Country:US
Practice Address - Phone:631-983-6665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist