Provider Demographics
NPI:1326082363
Name:FLEMING, KEVIN L (DDS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:L
Last Name:FLEMING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 S FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5117
Mailing Address - Country:US
Mailing Address - Phone:209-369-8218
Mailing Address - Fax:209-368-2102
Practice Address - Street 1:828 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5117
Practice Address - Country:US
Practice Address - Phone:209-369-8218
Practice Address - Fax:209-368-2102
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40587122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4058701Other1
CAB4058702Medicaid