Healthcare Provider Details

I. General information

NPI: 1093164980
Provider Name (Legal Business Name): KALEB MARTINEAU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15341 W WADDELL RD STE B107
SURPRISE AZ
85379-5169
US

IV. Provider business mailing address

1770 E 5625 S STE 2
SOUTH OGDEN UT
84403-5067
US

V. Phone/Fax

Practice location:
  • Phone: 623-975-3933
  • Fax:
Mailing address:
  • Phone: 801-475-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009464
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9464
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: