Healthcare Provider Details

I. General information

NPI: 1215026315
Provider Name (Legal Business Name): STUART D MARSHALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S MAIN ST STE 1
DRIGGS ID
83455
US

IV. Provider business mailing address

150 S MAIN ST STE 1
DRIGGS ID
83422
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-9700
  • Fax: 208-354-9701
Mailing address:
  • Phone: 208-354-9700
  • Fax: 208-354-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3890
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: