Healthcare Provider Details

I. General information

NPI: 1528118239
Provider Name (Legal Business Name): JERRY LEE MARSHALL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135A-B RADIO CITY DRIVE
NORTH PEKIN IL
61554
US

IV. Provider business mailing address

466 S PRAIRIE ST
BETHALTO IL
62010-1816
US

V. Phone/Fax

Practice location:
  • Phone: 309-382-2229
  • Fax: 309-382-1155
Mailing address:
  • Phone: 618-377-2482
  • Fax: 618-377-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: