MEDICARE: DR. JAMES DAMON MARZELLA DDS

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	D10435	MN

General Provider Information

NPI Number	:	1568431492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES DAMON MARZELLA DDS

Provider Business Mailing Address
First Line	:	PO BOX 23029
Second Line	:
City	:	RICHFIELD
State	:	MN
Zip	:	55423-0029
Country	:	US
Telephone Number	:	612-861-9123
Fax Number	:	612-861-9155

Provider Business Practice Location Address
First Line	:	6601 LYNDALE AVE S
Second Line	:	WOODLAKE CENTER, SUITE 230
City	:	RICHFIELD
State	:	MN
Zip	:	55423-2477
Country	:	US
Telephone Number	:	612-861-9123
Fax Number	:	612-861-9155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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