Provider Demographics
NPI:1902130404
Name:MARRIOTT, JUSTIN KENNETH ((DDS))
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KENNETH
Last Name:MARRIOTT
Suffix:
Gender:M
Credentials:(DDS)
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:
Other - Last Name:MARRIOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:201 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3038
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:
Practice Address - Street 1:309 SW 59TH ST
Practice Address - Street 2:#105
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-8321
Practice Address - Country:US
Practice Address - Phone:405-631-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7439272-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice