Provider Demographics
NPI:1487632972
Name:MARQUARDT, KENNETH LEE (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:MARQUARDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 POLARIS ST
Mailing Address - Street 2:
Mailing Address - City:WHITE SANDS MISSILE RANGE
Mailing Address - State:NM
Mailing Address - Zip Code:88002-1074
Mailing Address - Country:US
Mailing Address - Phone:505-678-8707
Mailing Address - Fax:
Practice Address - Street 1:128 CHAFFEE
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-3811
Practice Address - Country:US
Practice Address - Phone:915-568-1101
Practice Address - Fax:915-568-4113
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX153491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice