MEDICARE: DR. MARILYN VIGIL KETCHAM DDS

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	DD2546	NM
2	122300000X	Dentist	6990	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6990	OTHER	CO	COLORADO DENTAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	DD2546	OTHER	NM	DENTAL STATE LICENSE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	CS00210277	OTHER	NM	BOARD OF PHARMACY NUMBER

General Provider Information

NPI Number	:	1881790509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARILYN VIGIL KETCHAM DDS

Provider Business Mailing Address
First Line	:	3800 YORK ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-3540
Country	:	US
Telephone Number	:	303-296-4873
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 YORK ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-3540
Country	:	US
Telephone Number	:	303-296-4873
Fax Number	:

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	09/06/2011

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