Provider Demographics
NPI:1386128239
Name:FERNANDO, KEVIN MATTHEW
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MATTHEW
Last Name:FERNANDO
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 1:2683 OAK RD APT 232
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-7803
Mailing Address - Country:US
Mailing Address - Phone:714-350-3948
Mailing Address - Fax:
Practice Address - Street 1:1901 OLYMPIC BLVD STE 105
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5024
Practice Address - Country:US
Practice Address - Phone:925-935-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102927122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist