Provider Demographics
NPI:1144324302
Name:MARSHALL, DAVID S (DMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 RIDGE STREET
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503
Mailing Address - Country:US
Mailing Address - Phone:712-328-8892
Mailing Address - Fax:
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:SUITE 308
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-328-8892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA57051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0075564Medicaid
IA53950Medicare ID - Type Unspecified
IA0075564Medicaid