Provider Demographics
NPI:1063823870
Name:SUZANNE R. MERICLE, DMD, PC
Entity Type:Organization
Organization Name:SUZANNE R. MERICLE, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MERICLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:912-638-3559
Mailing Address - Street 1:123 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1680
Mailing Address - Country:US
Mailing Address - Phone:912-638-3559
Mailing Address - Fax:912-638-0360
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1680
Practice Address - Country:US
Practice Address - Phone:912-638-3559
Practice Address - Fax:912-638-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011052332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000484294AMedicaid