Healthcare Provider Details

I. General information

NPI: 1942636535
Provider Name (Legal Business Name): AKSANA MARSHALL D.M.D, M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 LOVE AVE STE A
TIFTON GA
31794-4000
US

IV. Provider business mailing address

1249 BRYAN ST W
DOUGLAS GA
31533-2001
US

V. Phone/Fax

Practice location:
  • Phone: 706-288-9582
  • Fax:
Mailing address:
  • Phone: 706-288-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014087
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN014087
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: