Provider Demographics
NPI:1568562528
Name:MARSHACK, KENNETH I (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:MARSHACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20322 NE INTERLACHEN LN
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-8727
Mailing Address - Country:US
Mailing Address - Phone:503-661-6114
Mailing Address - Fax:503-661-6114
Practice Address - Street 1:6600 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5250
Practice Address - Country:US
Practice Address - Phone:503-284-4723
Practice Address - Fax:503-284-5827
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR52681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice