Provider Demographics
NPI:1487879946
Name:MARTI, KENNETH R (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:MARTI
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 1:6049 DOUGLAS BLVD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6284
Mailing Address - Country:US
Mailing Address - Phone:916-791-4133
Mailing Address - Fax:916-791-1659
Practice Address - Street 1:6049 DOUGLAS BLVD
Practice Address - Street 2:SUITE 9
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6284
Practice Address - Country:US
Practice Address - Phone:916-791-4133
Practice Address - Fax:916-791-1659
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA# 274531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice