Provider Demographics
NPI:1184989782
Name:MARSHALL, BLAIRE L (DDS)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:L
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17515 SPRING CYPRESS RD STE I
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-2689
Mailing Address - Country:US
Mailing Address - Phone:281-304-4280
Mailing Address - Fax:281-304-4286
Practice Address - Street 1:MANSFIELD MODERN DENTISTRY
Practice Address - Street 2:287 SCHOOL ST STE 120
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-0204
Practice Address - Country:US
Practice Address - Phone:918-640-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858554122300000X
TX28151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist