Provider Demographics
NPI:1851404412
Name:WILLIAM S MARIETTA DDS INC
Entity Type:Organization
Organization Name:WILLIAM S MARIETTA DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARIETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-247-8005
Mailing Address - Street 1:717 ENCINO PL NE
Mailing Address - Street 2:#6
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102
Mailing Address - Country:US
Mailing Address - Phone:505-247-8005
Mailing Address - Fax:505-843-8589
Practice Address - Street 1:717 ENCINO PL NE
Practice Address - Street 2:#6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-247-8005
Practice Address - Fax:505-843-8589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty