Provider Demographics
NPI:1992999130
Name:HUMES, MARSHALL SHERIDAN (DDS)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:SHERIDAN
Last Name:HUMES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 PASEO LADERA LANE
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420
Mailing Address - Country:US
Mailing Address - Phone:805-441-1552
Mailing Address - Fax:805-349-8551
Practice Address - Street 1:2151 S. COLLEGE DRIVE, SUITE 104
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455
Practice Address - Country:US
Practice Address - Phone:805-925-1440
Practice Address - Fax:805-925-1251
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T70440Medicare UPIN