Provider Demographics
NPI:1457672669
Name:MARRIOTT, KENNETH ROBERT (KEN MARRIOTT DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:MARRIOTT
Suffix:
Gender:M
Credentials:KEN MARRIOTT DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40255 GRAND RIVER AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-4837
Practice Address - Country:US
Practice Address - Phone:248-442-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020226122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist