Provider Demographics
NPI:1710077078
Name:BAILEY, MARSHALL SCOTT (DMD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:SCOTT
Last Name:BAILEY
Suffix:
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 1:75 SAN MARCO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3257
Mailing Address - Country:US
Mailing Address - Phone:904-810-1002
Mailing Address - Fax:904-823-9784
Practice Address - Street 1:75 SAN MARCO AVE
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-3257
Practice Address - Country:US
Practice Address - Phone:904-810-1002
Practice Address - Fax:904-823-9784
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL155341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice