Healthcare Provider Details

I. General information

NPI: 1316942766
Provider Name (Legal Business Name): SAMUEL JESSE MARSH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 BUSH RIVER RD
COLUMBIA SC
29210-5649
US

IV. Provider business mailing address

2302 BUSH RIVER RD
COLUMBIA SC
29210-5649
US

V. Phone/Fax

Practice location:
  • Phone: 803-798-8675
  • Fax: 803-798-4753
Mailing address:
  • Phone: 803-798-8675
  • Fax: 803-798-4753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1192
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: