Provider Demographics
NPI:1790330389
Name:MARCEL J. DANEAULT, JR., DDS, LLC
Entity Type:Organization
Organization Name:MARCEL J. DANEAULT, JR., DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-356-4522
Mailing Address - Street 1:1124 BLACK GOLD PL
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1876
Mailing Address - Country:US
Mailing Address - Phone:614-296-7314
Mailing Address - Fax:
Practice Address - Street 1:5715 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-1325
Practice Address - Country:US
Practice Address - Phone:614-467-8000
Practice Address - Fax:614-467-8020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARCEL J. DANEAULT, JR., DDS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0161522Medicaid