Provider Demographics
NPI:1093164980
Name:MARTINEAU, KALEB (DMD)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:MARTINEAU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E 5625 S STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5067
Mailing Address - Country:US
Mailing Address - Phone:801-475-1999
Mailing Address - Fax:
Practice Address - Street 1:15341 W WADDELL RD STE B107
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-5169
Practice Address - Country:US
Practice Address - Phone:623-975-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD94641223G0001X
AZD009464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice