Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant |
NPI | 1215574421 |
---|---|
Provider Name | Kevin Jesus Martinez |
First Address | Vista, CA 92081-6373 |
Second Address | Jacksonville, FL 32212-0140 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2019 |
Last Update Date | 06/12/2019 |