Provider Demographics
NPI:1669622155
Name:MARIETTA, WILLIAM S (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:S
Last Name:MARIETTA
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 1:717 ENCINO PL NE
Mailing Address - Street 2:SUITE: 6
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2611
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:SUITE: 6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2611
Practice Address - Country:US
Practice Address - Phone:505-247-8005
Practice Address - Fax:505-843-8589
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1415122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist