MEDICARE: MARDEN DENTAL

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	1223G0001X	General Practice Dentistry	DE015190	MO

General Provider Information

NPI Number	:	1255510988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARDEN DENTAL

Provider Business Mailing Address
First Line	:	10322 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1521
Country	:	US
Telephone Number	:	314-822-4521
Fax Number	:	314-822-4527

Provider Business Practice Location Address
First Line	:	10322 MANCHESTER RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-1521
Country	:	US
Telephone Number	:	314-822-4521
Fax Number	:	314-822-4527

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARSHA L MARDEN
Credential	:	DMD
Telephone Number	:	314-822-4521

Provider Enumeration Date	:	10/30/2007
Last Update Date	:	10/30/2007

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