Provider Demographics
NPI:1922023563
Name:DEAN, KEVIN C (DMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:DEAN
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 1:4850 N 9TH AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2406
Mailing Address - Country:US
Mailing Address - Phone:850-477-1125
Mailing Address - Fax:850-479-5809
Practice Address - Street 1:4850 N 9TH AVE STE 4
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2406
Practice Address - Country:US
Practice Address - Phone:850-477-1125
Practice Address - Fax:850-479-5809
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00126751223S0112X
AL48351223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071631600Medicaid
AL009973460Medicaid
FLG17232Medicare UPIN
FL56830AMedicare ID - Type Unspecified