=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528071305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARSHALL FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3443 TAMIAMI TRL SUITE F
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-8187
-----------------------------------------------------
Fax | 941-629-2498
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3443 TAMIAMI TRL SUITE F
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33952-8159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-8187
-----------------------------------------------------
Fax | 941-629-2498
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PARTNER
-----------------------------------------------------
Name | DR. PHILIP LEWIS MARSHALL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 941-629-8187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN0011485
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------