Provider Demographics
NPI:1801346630
Name:MA, KEVIN (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MA
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 1:111 BEAN CREEK RD UNIT 51
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4138
Mailing Address - Country:US
Mailing Address - Phone:831-332-5477
Mailing Address - Fax:
Practice Address - Street 1:221 MOUNT HERMON RD STE H
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4038
Practice Address - Country:US
Practice Address - Phone:831-440-1830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1006531223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice