Provider Demographics
NPI:1225595432
Name:BARAJAS, KEVIN MICHAEL
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:BARAJAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SHERMAN ST W SUITE 3A
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5849
Mailing Address - Country:US
Mailing Address - Phone:619-495-9444
Mailing Address - Fax:
Practice Address - Street 1:140 SHERMAN ST W SUITE 3A
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5849
Practice Address - Country:US
Practice Address - Phone:619-495-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT130631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice