1881790509 NPI number — DR. MARILYN VIGIL KETCHAM DDS

Table of content: DR. MARILYN VIGIL KETCHAM DDS (NPI 1881790509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881790509 NPI number — DR. MARILYN VIGIL KETCHAM DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETCHAM
Provider First Name:
MARILYN
Provider Middle Name:
VIGIL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881790509
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80205-3540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-296-4873
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 YORK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80205-3540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-296-4873
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DD2546 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 6990 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6990 . This is a "COLORADO DENTAL LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 87384043 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD2546 . This is a "DENTAL STATE LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 02069904 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS00210277 . This is a "BOARD OF PHARMACY NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com