Healthcare Provider Details

I. General information

NPI: 1487858106
Provider Name (Legal Business Name): KURT OTTO MARCKS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24099 POSTAL AVE SUITE 101
MORENO VALLEY CA
92553-7709
US

IV. Provider business mailing address

24099 POSTAL AVE SUITE 101
MORENO VALLEY CA
92553-7709
US

V. Phone/Fax

Practice location:
  • Phone: 951-601-1290
  • Fax: 951-601-1292
Mailing address:
  • Phone: 951-601-1290
  • Fax: 951-601-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number42360
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: