Provider Demographics
NPI:1356302657
Name:MARTIN, KEITH ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALBERT
Last Name:MARTIN
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 1:9100 E 29TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2177
Mailing Address - Country:US
Mailing Address - Phone:316-634-0990
Mailing Address - Fax:316-634-1781
Practice Address - Street 1:9100 E 29TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2177
Practice Address - Country:US
Practice Address - Phone:316-634-0990
Practice Address - Fax:316-634-1781
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice