Provider Demographics
NPI:1487605747
Name:GARVIN, KEVIN JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:GARVIN
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 1:118 EAST 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425
Mailing Address - Country:US
Mailing Address - Phone:707-894-2514
Mailing Address - Fax:707-894-8404
Practice Address - Street 1:118 EAST 2ND STREET
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425
Practice Address - Country:US
Practice Address - Phone:707-894-2514
Practice Address - Fax:707-894-8404
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39527122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3952701Medicaid