Provider Demographics
NPI:1730951435
Name:CHADWICK J MARSHALL DMD MD PA DBA GULF COAST FACIAL AND ORAL SURGERY
Entity type:Organization
Organization Name:CHADWICK J MARSHALL DMD MD PA DBA GULF COAST FACIAL AND ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CHADWICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:850-269-7550
Mailing Address - Street 1:105 HOLLYWOOD BLVD NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 HOLLYWOOD BLVD NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4922
Practice Address - Country:US
Practice Address - Phone:850-269-7550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty