Provider Demographics
NPI:1528118239
Name:MARSHALL, JERRY LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
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 1:466 S PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-1816
Mailing Address - Country:US
Mailing Address - Phone:618-377-2482
Mailing Address - Fax:618-377-5228
Practice Address - Street 1:135A-B RADIO CITY DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554
Practice Address - Country:US
Practice Address - Phone:309-382-2229
Practice Address - Fax:309-382-1155
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice