Provider Demographics
NPI:1043839731
Name:MARSH, DALLAS (DO)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:MARSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 ROUTE 62
Mailing Address - Street 2:
Mailing Address - City:KENNEDY
Mailing Address - State:NY
Mailing Address - Zip Code:14747-9519
Mailing Address - Country:US
Mailing Address - Phone:716-338-3836
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program