Provider Demographics
NPI:1275010134
Name:MERCHANT, MUIZZ
Entity Type:Individual
Prefix:
First Name:MUIZZ
Middle Name:
Last Name:MERCHANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 COG CIR STE H
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7301
Mailing Address - Country:US
Mailing Address - Phone:779-220-4396
Mailing Address - Fax:
Practice Address - Street 1:720 COG CIR STE H
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7301
Practice Address - Country:US
Practice Address - Phone:779-220-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0318011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice