Healthcare Provider Details

I. General information

NPI: 1104869775
Provider Name (Legal Business Name): JOHN CLYDE MARIETTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W CLOUD ST
SALINA KS
67401-6448
US

IV. Provider business mailing address

208 W CLOUD ST
SALINA KS
67401-6448
US

V. Phone/Fax

Practice location:
  • Phone: 785-825-7557
  • Fax: 785-825-7666
Mailing address:
  • Phone: 785-825-7557
  • Fax: 785-825-7666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5766
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: