Provider Demographics
NPI:1003096579
Name:SELENA L MARCHAN, DMD, PA
Entity Type:Organization
Organization Name:SELENA L MARCHAN, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-221-5678
Mailing Address - Street 1:13475 ATLANTIC BLVD STE 36
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3290
Mailing Address - Country:US
Mailing Address - Phone:904-221-5678
Mailing Address - Fax:904-220-5678
Practice Address - Street 1:13475 ATLANTIC BLVD
Practice Address - Street 2:STE 36
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3291
Practice Address - Country:US
Practice Address - Phone:904-246-2603
Practice Address - Fax:904-247-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2015-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL816281OtherUNITED CONCORDIA