Provider Demographics
NPI:1760557334
Name:MARTIN, KENNETH R (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
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 1:694 S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3882
Mailing Address - Country:US
Mailing Address - Phone:931-528-5491
Mailing Address - Fax:931-520-0510
Practice Address - Street 1:694 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3882
Practice Address - Country:US
Practice Address - Phone:931-528-5491
Practice Address - Fax:931-520-0510
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS27661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice