Provider Demographics
NPI:1962187963
Name:MARSHALL, RICHARD A JR (DMD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MARSHALL
Suffix:JR
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 1:8957 W RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2021
Mailing Address - Country:US
Mailing Address - Phone:480-208-3079
Mailing Address - Fax:
Practice Address - Street 1:18301 N 79TH AVE STE G186
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6093
Practice Address - Country:US
Practice Address - Phone:480-208-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011833122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice