Provider Demographics
NPI:1417010539
Name:MARSHALL, STEPHEN G (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:MARSHALL
Suffix:
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 1:10510 W CERMAK ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5202
Mailing Address - Country:US
Mailing Address - Phone:708-562-5526
Mailing Address - Fax:708-562-9532
Practice Address - Street 1:10510 W CERMAK ROAD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5202
Practice Address - Country:US
Practice Address - Phone:708-562-5526
Practice Address - Fax:708-562-9532
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL627251Medicare ID - Type Unspecified