Provider Demographics
NPI:1932568144
Name:PALMER, MARTIN KEALI'I (DMD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:KEALI'I
Last Name:PALMER
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 1:1910 CUSTOMER CARE WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5167
Mailing Address - Country:US
Mailing Address - Phone:209-384-6493
Mailing Address - Fax:
Practice Address - Street 1:747 W CHILDS AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6805
Practice Address - Country:US
Practice Address - Phone:209-383-5464
Practice Address - Fax:209-383-6624
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA10100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program