Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 19010764 | IL |
N | 1223P0700X | Prosthodontist | 19010764 | IL |
NPI | 1114187721 |
---|---|
Provider Name | Dr. Martin Marshack |
First Address | Northbrook, IL 60062-2129 |
Second Address | Northbrook, IL 60062-2129 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2008 |
Last Update Date | 17/06/2008 |