Provider Demographics
NPI:1013278464
Name:MARTIN, KELLY (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
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:G4007 W COURT ST
Mailing Address - Street 2:#D
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3560
Mailing Address - Country:US
Mailing Address - Phone:810-230-0077
Mailing Address - Fax:
Practice Address - Street 1:G4007 W COURT ST
Practice Address - Street 2:#D
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3560
Practice Address - Country:US
Practice Address - Phone:810-230-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010206771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice