Provider Demographics
NPI:1699752287
Name:KURTZ, MARSHALL D (DMD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:D
Last Name:KURTZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7504
Mailing Address - Country:US
Mailing Address - Phone:203-790-0183
Mailing Address - Fax:203-743-7401
Practice Address - Street 1:129 PARK AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7504
Practice Address - Country:US
Practice Address - Phone:203-790-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT92911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002092914Medicaid
CTU99596Medicare ID - Type Unspecified
CT002092914Medicaid
CT190000981Medicare PIN