Provider Demographics
NPI:1679559231
Name:MARTIN, KEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:
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 1:4138 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-6060
Mailing Address - Country:US
Mailing Address - Phone:727-849-0705
Mailing Address - Fax:727-847-3851
Practice Address - Street 1:4138 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-6060
Practice Address - Country:US
Practice Address - Phone:727-849-0705
Practice Address - Fax:727-847-3851
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist