=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003096579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELENA L MARCHAN, DMD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2007
-----------------------------------------------------
Last Update Date | 03/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13475 ATLANTIC BLVD STE 36
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225-3291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-246-2603
-----------------------------------------------------
Fax | 904-247-9663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13475 ATLANTIC BLVD STE 36
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225-3290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-221-5678
-----------------------------------------------------
Fax | 904-220-5678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SELENA L MARCHAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 904-221-5678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN13459
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------