Healthcare Provider Details

I. General information

NPI: 1245430305
Provider Name (Legal Business Name): CHARLES THOMAS MARSHALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 FORT ST
NEAH BAY WA
98357-0410
US

IV. Provider business mailing address

250 FORT ST
NEAH BAY WA
98357-0410
US

V. Phone/Fax

Practice location:
  • Phone: 360-645-2233
  • Fax: 360-645-2305
Mailing address:
  • Phone: 360-645-2233
  • Fax: 360-645-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60107500
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: