Provider Demographics
NPI:1346488236
Name:FREERKS, MARSHALL CORNELIUS JR (DDS)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:CORNELIUS
Last Name:FREERKS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6744 CLAYTON RD.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1634
Mailing Address - Country:US
Mailing Address - Phone:314-725-5515
Mailing Address - Fax:
Practice Address - Street 1:6744 CLAYTON RD.
Practice Address - Street 2:SUITE 204
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1634
Practice Address - Country:US
Practice Address - Phone:314-725-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14600122300000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentist