1003096579 NPI number — SELENA L MARCHAN, DMD, PA

Table of content: (NPI 1003096579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003096579 NPI number — SELENA L MARCHAN, DMD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELENA L MARCHAN, DMD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003096579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13475 ATLANTIC BLVD STE 36
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32225-3290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-221-5678
Provider Business Mailing Address Fax Number:
904-220-5678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13475 ATLANTIC BLVD
Provider Second Line Business Practice Location Address:
STE 36
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32225-3291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-246-2603
Provider Business Practice Location Address Fax Number:
904-247-9663
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARCHAN
Authorized Official First Name:
SELENA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-221-5678

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN13459 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 816281 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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