Provider Demographics
NPI:1477830362
Name:MA, KEVIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:MA
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 1:32 OLD TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2446
Mailing Address - Country:US
Mailing Address - Phone:215-485-8757
Mailing Address - Fax:
Practice Address - Street 1:32 OLD TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2446
Practice Address - Country:US
Practice Address - Phone:215-485-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037995122300000X, 1223P0300X
NY0563131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist