Provider Demographics
NPI:1689765968
Name:VANNESS, MARC ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ROBERT
Last Name:VANNESS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LAKE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3706
Mailing Address - Country:US
Mailing Address - Phone:719-375-5201
Mailing Address - Fax:844-656-9696
Practice Address - Street 1:155 LAKE AVE STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3706
Practice Address - Country:US
Practice Address - Phone:719-375-5201
Practice Address - Fax:844-656-9696
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD1049091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02049096Medicaid