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General NPI Number Information
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NPI Number | 1508065715
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Entity Type | Organization
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Legal Business Name | MARSHALL DENTAL GROUP
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Dates
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Enumeration Date | 07/17/2007
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Last Update Date | 07/17/2007
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Provider Practice Location Address
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Address Line | 6200 WILSHIRE BLVD #1709
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City | LOS ANGELES
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State | CA
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Zip | 90048-5801
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Country | US
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Telephone | 323-634-6334
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Fax | 323-634-6338
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Provider Business Mailing Address
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Address Line | 6200 WILSHIRE BLVD #1709
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City | LOS ANGELES
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State | CA
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Zip | 90048-5801
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Country | US
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Telephone | 323-634-6334
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Fax | 323-634-6338
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Authorized Official
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Title or Position | OWNER
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Name | DR. DEREK SPENCER MARSHALL SR.
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Credential | DDS
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Telephone | 323-634-6334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 34163
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License Number State | CA
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