Healthcare Provider Details

I. General information

NPI: 1255300166
Provider Name (Legal Business Name): DENNIS JAMES MARSHALL CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 TIMBERLAND DR
FAIRBANKS AK
99701-3143
US

IV. Provider business mailing address

13 TIMBERLAND DR
FAIRBANKS AK
99701-3143
US

V. Phone/Fax

Practice location:
  • Phone: 907-374-3381
  • Fax: 907-374-3380
Mailing address:
  • Phone: 907-374-3381
  • Fax: 907-374-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCPO00873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: