Provider Demographics
NPI:1609910215
Name:MARTIN, KATHLEEN M (RDH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CONE AVE
Mailing Address - Street 2:
Mailing Address - City:CASCO
Mailing Address - State:ME
Mailing Address - Zip Code:04015-4328
Mailing Address - Country:US
Mailing Address - Phone:207-541-6628
Mailing Address - Fax:207-541-6891
Practice Address - Street 1:389 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3509
Practice Address - Country:US
Practice Address - Phone:207-541-6628
Practice Address - Fax:207-541-6891
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0911124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist