Healthcare Provider Details

I. General information

NPI: 1750423257
Provider Name (Legal Business Name): KENNETH MARCUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 OCEAN PARKWAY SUITE 1A
BROOKLYN NY
11223
US

IV. Provider business mailing address

1750 OCEAN PARKWAY SUITE 1A
BROOKLYN NY
11223
US

V. Phone/Fax

Practice location:
  • Phone: 718-375-7760
  • Fax: 718-375-7760
Mailing address:
  • Phone: 718-375-7760
  • Fax: 718-375-7760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number035220
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: