Provider Demographics
NPI:1962918425
Name:MARSHALL DENTAL CARE, LLC
Entity type:Organization
Organization Name:MARSHALL DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:660-886-6843
Mailing Address - Street 1:263 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-2134
Mailing Address - Country:US
Mailing Address - Phone:660-886-6843
Mailing Address - Fax:660-886-7855
Practice Address - Street 1:263 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-2134
Practice Address - Country:US
Practice Address - Phone:660-886-6843
Practice Address - Fax:660-886-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12712261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental