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General NPI Number Information
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NPI Number | 1245619956
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Entity Type | Organization
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Legal Business Name | KEVIN A DELORIA DDS
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Dates
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Enumeration Date | 05/27/2015
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Last Update Date | 05/27/2015
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Provider Practice Location Address
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Address Line | 1690 S OHIO ST
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City | MARTINSVILLE
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State | IN
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Zip | 46151-3317
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Country | US
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Telephone | 765-342-8435
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Fax | 765-342-3561
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Provider Business Mailing Address
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Address Line | 1690 S OHIO ST
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City | MARTINSVILLE
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State | IN
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Zip | 46151-3317
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Country | US
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Telephone | 765-342-8435
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Fax | 765-342-3561
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KEVIN A DELORIA
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Credential | DDS
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Telephone | 765-342-8435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12009312
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License Number State | IN
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