MEDICARE: MARQUE MANAGEMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3568	NH

General Provider Information

NPI Number	:	1033393624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARQUE MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	373 S WILLOW ST
Second Line	:	SUITE D1-6
City	:	MANCHESTER
State	:	NH
Zip	:	03103-5751
Country	:	US
Telephone Number	:	603-622-6288
Fax Number	:

Provider Business Practice Location Address
First Line	:	373 S WILLOW ST
Second Line	:	SUITE D1-6
City	:	MANCHESTER
State	:	NH
Zip	:	03103-5751
Country	:	US
Telephone Number	:	603-622-6288
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SHANNON M FARRELL
Credential	:	D.M.D.
Telephone Number	:	603-622-6288

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	12/19/2007

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