Provider Demographics
NPI:1073671533
Name:MERICLE, SUZANNE R (DMD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:R
Last Name:MERICLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT 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:SAINT 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0110521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000484294AMedicaid