Provider Demographics
NPI:1275594186
Name:MARSHALL, MICHAEL (DDS, MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 5TH AVE
Mailing Address - Street 2:SUITE 1709
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-7701
Mailing Address - Country:US
Mailing Address - Phone:212-488-7777
Mailing Address - Fax:
Practice Address - Street 1:261 5TH AVE
Practice Address - Street 2:SUITE 1709
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-7701
Practice Address - Country:US
Practice Address - Phone:212-488-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0458801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02187382Medicaid