Provider Demographics
NPI:1891034138
Name:MARSHALL, RICHARD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MARSHALL
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 1:120 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-9736
Mailing Address - Country:US
Mailing Address - Phone:304-645-3110
Mailing Address - Fax:304-645-3209
Practice Address - Street 1:120 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-9736
Practice Address - Country:US
Practice Address - Phone:304-645-3110
Practice Address - Fax:304-645-3209
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1914122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135577000Medicaid