MEDICARE: KALEB MARTINEAU DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D9464	AZ
2	122300000X	Dentist	D009464	AZ

General Provider Information

NPI Number	:	1093164980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALEB MARTINEAU DMD

Provider Business Mailing Address
First Line	:	1770 E 5625 S STE 2
Second Line	:
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-5067
Country	:	US
Telephone Number	:	801-475-1999
Fax Number	:

Provider Business Practice Location Address
First Line	:	15341 W WADDELL RD STE B107
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85379-5169
Country	:	US
Telephone Number	:	623-975-3933
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2016
Last Update Date	:	01/11/2021

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