Provider Demographics
NPI:1215169420
Name:KISS, MARJORIE CHRISTIANE (RDA)
Entity type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:CHRISTIANE
Last Name:KISS
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1958
Mailing Address - Country:US
Mailing Address - Phone:909-392-3565
Mailing Address - Fax:
Practice Address - Street 1:440 E HUNTINGTON DR STE 101
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3750
Practice Address - Country:US
Practice Address - Phone:626-447-5126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34731126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant