Provider Demographics
NPI:1881790509
Name:KETCHAM, MARILYN VIGIL (DDS)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:VIGIL
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 YORK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-3540
Mailing Address - Country:US
Mailing Address - Phone:303-296-4873
Mailing Address - Fax:
Practice Address - Street 1:3800 YORK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-3540
Practice Address - Country:US
Practice Address - Phone:303-296-4873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2546122300000X
CO6990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6990OtherCOLORADO DENTAL LICENSE
NM87384043Medicaid
NMDD2546OtherDENTAL STATE LICENSE
CO02069904Medicaid
NMCS00210277OtherBOARD OF PHARMACY NUMBER