Provider Demographics
NPI:1487642914
Name:MARTIN, KEVIN A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:MARTIN
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 1:164 COMMACK RD
Mailing Address - Street 2:STE #7
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3430
Mailing Address - Country:US
Mailing Address - Phone:631-462-4600
Mailing Address - Fax:631-462-4602
Practice Address - Street 1:164 COMMACK RD
Practice Address - Street 2:STE #7
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3430
Practice Address - Country:US
Practice Address - Phone:631-462-4600
Practice Address - Fax:631-462-4602
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049501-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist