MEDICARE: DR. MARY JANE MARSHALL 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	1223G0001X	General Practice Dentistry	4373	NC

General Provider Information

NPI Number	:	1700186426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY JANE MARSHALL DDS

Provider Business Mailing Address
First Line	:	PO BOX 2581
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27906-2581
Country	:	US
Telephone Number	:	252-338-1195
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 N TRYON ST
Second Line	:	SUITE 1600, PMB 209
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-0202
Country	:	US
Telephone Number	:	252-338-1195
Fax Number	:

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

Provider Enumeration Date	:	10/28/2010
Last Update Date	:	10/28/2010

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