Provider Demographics
NPI:1093931396
Name:KENNETH R, MARTI DDS INC.
Entity Type:Organization
Organization Name:KENNETH R, MARTI DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS INC
Authorized Official - Phone:916-791-4133
Mailing Address - Street 1:6049 DOUGLAS BLVD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6284
Mailing Address - Country:US
Mailing Address - Phone:916-791-4133
Mailing Address - Fax:916-791-1659
Practice Address - Street 1:6049 DOUGLAS BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6284
Practice Address - Country:US
Practice Address - Phone:916-791-4133
Practice Address - Fax:916-791-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27453261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental