Provider Demographics
NPI:1083694491
Name:PRUCHA, MERRILYN PETERSON (RDH)
Entity Type:Individual
Prefix:MS
First Name:MERRILYN
Middle Name:PETERSON
Last Name:PRUCHA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 EASTOVER CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8911
Mailing Address - Country:US
Mailing Address - Phone:757-314-7190
Mailing Address - Fax:
Practice Address - Street 1:1550 TOMCAT BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2218
Practice Address - Country:US
Practice Address - Phone:757-314-7190
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402002559124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist