MEDICARE: GLORY B MARSHALL D.D.S., M.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	16208	TX

General Provider Information

NPI Number	:	1710022645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORY B MARSHALL D.D.S., M.S.

Provider Business Mailing Address
First Line	:	999 E BASSE RD STE 155
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1806
Country	:	US
Telephone Number	:	210-822-1110
Fax Number	:	210-822-1379

Provider Business Practice Location Address
First Line	:	999 E BASSE RD STE 155
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1806
Country	:	US
Telephone Number	:	210-822-1110
Fax Number	:	210-822-1379

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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