Provider Demographics
NPI:1700347812
Name:MARTIN, AMMERA KAING (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMMERA
Middle Name:KAING
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 1:1890 JUNCTION BLVD APT 2324
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4703
Mailing Address - Country:US
Mailing Address - Phone:209-242-1311
Mailing Address - Fax:
Practice Address - Street 1:5401 ARNOLD AVE # 88
Practice Address - Street 2:
Practice Address - City:MCCLELLAN
Practice Address - State:CA
Practice Address - Zip Code:95652-1018
Practice Address - Country:US
Practice Address - Phone:209-242-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1033551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice