Provider Demographics
NPI:1619130085
Name:MARTIN, KENDRA DAWN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:DAWN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 VIRGINIA ST E
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-2951
Mailing Address - Country:US
Mailing Address - Phone:304-342-4422
Mailing Address - Fax:
Practice Address - Street 1:1218 VIRGINIA ST E
Practice Address - Street 2:SUITE D
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2951
Practice Address - Country:US
Practice Address - Phone:304-342-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38271223G0001X
PADS037979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist