Healthcare Provider Details

I. General information

NPI: 1649263039
Provider Name (Legal Business Name): KIMBERLY MARTIN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E UNIVERSITY AVE STE B
LAS CRUCES NM
88001-5637
US

IV. Provider business mailing address

705 E UNIVERSITY AVE STE B
LAS CRUCES NM
88001-5637
US

V. Phone/Fax

Practice location:
  • Phone: 505-521-0127
  • Fax: 505-647-9533
Mailing address:
  • Phone: 505-521-0127
  • Fax: 505-647-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2317
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: