Provider Demographics
NPI:1124129531
Name:MARSHALL, PHILIP LEWIS (DMD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:LEWIS
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 1:4080 LEA MARIE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9191
Mailing Address - Country:US
Mailing Address - Phone:941-627-8872
Mailing Address - Fax:941-629-2498
Practice Address - Street 1:3443 TAMIAMI TRL
Practice Address - Street 2:SUITE F
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8159
Practice Address - Country:US
Practice Address - Phone:941-629-8187
Practice Address - Fax:941-629-2498
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00114851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice