MEDICARE: DR. KATHRYN RICKS MARKS D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2901020308	MI

General Provider Information

NPI Number	:	1629387089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHRYN RICKS MARKS D.M.D.

Provider Business Mailing Address
First Line	:	4414 WOOD HOLLOW CIR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31605-6625
Country	:	US
Telephone Number	:	517-582-2335
Fax Number	:

Provider Business Practice Location Address
First Line	:	23 RD MEDICAL GROUP
Second Line	:	3278 MITCHELL BLVD
City	:	MOODY A F B
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-3136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	04/14/2014

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