Provider Demographics
NPI:1801001813
Name:MARTELLO, KEVIN DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:MARTELLO
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 1:5 STERLING RANCH RD N
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8535
Mailing Address - Country:US
Mailing Address - Phone:318-949-2074
Mailing Address - Fax:
Practice Address - Street 1:2114 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-9497
Practice Address - Country:US
Practice Address - Phone:318-949-8344
Practice Address - Fax:318-949-8344
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice