Provider Demographics
NPI:1215574421
Name:MARTINEZ, KEVIN JESUS
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JESUS
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 POMELO DR APT F20
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6373
Mailing Address - Country:US
Mailing Address - Phone:623-498-9984
Mailing Address - Fax:
Practice Address - Street 1:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - Street 2:BLDG H 2005 KNIGHT LANE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:760-725-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant