Provider Demographics
NPI:1104869775
Name:MARIETTA, JOHN CLYDE (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CLYDE
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 1:208 W CLOUD ST
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-6448
Mailing Address - Country:US
Mailing Address - Phone:785-825-7557
Mailing Address - Fax:785-825-7666
Practice Address - Street 1:208 W CLOUD ST
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-6448
Practice Address - Country:US
Practice Address - Phone:785-825-7557
Practice Address - Fax:785-825-7666
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS57661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice