Provider Demographics
NPI:1215026315
Name:MARSHALL, STUART D (DDS)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:D
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422
Mailing Address - Country:US
Mailing Address - Phone:208-354-9700
Mailing Address - Fax:208-354-9701
Practice Address - Street 1:150 S MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-354-9700
Practice Address - Fax:208-354-9701
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807204600Medicaid