Provider Demographics
NPI:1205356425
Name:MARSHALL, JOHN III (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MARSHALL
Suffix:III
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 1:2315 TECHNOLOGY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7371
Mailing Address - Country:US
Mailing Address - Phone:636-561-9255
Mailing Address - Fax:636-625-9028
Practice Address - Street 1:2315 TECHNOLOGY DR STE 101
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7371
Practice Address - Country:US
Practice Address - Phone:636-561-9255
Practice Address - Fax:636-625-9028
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180113631223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice