Provider Demographics
NPI:1952376295
Name:MARTIN, KEVIN MATHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MATHEW
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 W RUSSELL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5690
Mailing Address - Country:US
Mailing Address - Phone:702-570-3320
Mailing Address - Fax:702-570-3424
Practice Address - Street 1:9450 W RUSSELL RD STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5690
Practice Address - Country:US
Practice Address - Phone:702-312-2273
Practice Address - Fax:702-312-2276
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS2-261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002202729Medicaid