Provider Demographics
NPI:1386606937
Name:WADE, MARSHALL LLOYD (DDS)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:LLOYD
Last Name:WADE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 VALLEY CREEK RD
Mailing Address - Street 2:SUITE100
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4883
Mailing Address - Country:US
Mailing Address - Phone:651-578-7000
Mailing Address - Fax:651-578-0157
Practice Address - Street 1:1560 BEAM AVE STE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1171
Practice Address - Country:US
Practice Address - Phone:651-578-7000
Practice Address - Fax:651-773-9646
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND97341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1223S0112XOtherTAXONOMY NUMBER
MND9734OtherDENTAL LICENSE
MN772822100Medicaid
MN1223S0112XOtherTAXONOMY NUMBER
MN190000256Medicare ID - Type Unspecified