Provider Demographics
NPI:1508065715
Name:MARSHALL DENTAL GROUP
Entity Type:Organization
Organization Name:MARSHALL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-634-6334
Mailing Address - Street 1:6200 WILSHIRE BLVD
Mailing Address - Street 2:#1709
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5801
Mailing Address - Country:US
Mailing Address - Phone:323-634-6334
Mailing Address - Fax:323-634-6338
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:#1709
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-634-6334
Practice Address - Fax:323-634-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA341631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty