Provider Demographics
NPI:1144671652
Name:VALDEZ, MARK KEKOA
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:KEKOA
Last Name:VALDEZ
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:BLDG 39033 SUPPORT AVE FT, HOOD TX
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AA
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:808-430-1508
Mailing Address - Fax:
Practice Address - Street 1:US ARMY DENTAL ACTIVITY 4431 68TH STREET
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-287-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH01098950OtherDENTAL HYGIENIST