Provider Demographics
NPI:1669889093
Name:MENZIE, KEVIN LEON (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LEON
Last Name:MENZIE
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7930 FROST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2756
Mailing Address - Country:US
Mailing Address - Phone:858-492-9977
Mailing Address - Fax:
Practice Address - Street 1:7930 FROST ST STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2756
Practice Address - Country:US
Practice Address - Phone:858-492-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS104865122300000X, 1223X0400X
TX30222122300000X, 1223X0400X
AZD010279122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist