Healthcare Provider Details

I. General information

NPI: 1972629921
Provider Name (Legal Business Name): MARQUEZ JAMAR SAMS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N CARRIAGE PKWY
WICHITA KS
67208-4506
US

IV. Provider business mailing address

555 N CARRIAGE PKWY
WICHITA KS
67208-4506
US

V. Phone/Fax

Practice location:
  • Phone: 316-683-2525
  • Fax: 316-683-9385
Mailing address:
  • Phone: 316-683-2525
  • Fax: 316-683-9385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number60623
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: