Provider Demographics
NPI:1699113647
Name:MARSHALL, SHRADDHA ANDRE (DDS)
Entity type:Individual
Prefix:DR
First Name:SHRADDHA
Middle Name:ANDRE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHRADDHA
Other - Middle Name:VILAS
Other - Last Name:POWAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1956
Mailing Address - Country:US
Mailing Address - Phone:860-679-2505
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1956
Practice Address - Country:US
Practice Address - Phone:860-679-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT114381223G0001X
CT2.011438 PROV122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist