Provider Demographics
NPI:1295350130
Name:KONKLE, MARRIELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARRIELLE
Middle Name:
Last Name:KONKLE
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:COOPERSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49404-1308
Mailing Address - Country:US
Mailing Address - Phone:616-773-8717
Mailing Address - Fax:
Practice Address - Street 1:706 W RANDALL ST # 1306
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1308
Practice Address - Country:US
Practice Address - Phone:616-837-6521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016010211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice