Provider Demographics
NPI:1346940368
Name:PEEBLES, MARCELLA MERRIN (DMD)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:MERRIN
Last Name:PEEBLES
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 1:16700 BUCKLEY DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9227
Mailing Address - Country:US
Mailing Address - Phone:541-515-4942
Mailing Address - Fax:
Practice Address - Street 1:1725 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1862
Practice Address - Country:US
Practice Address - Phone:231-737-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2901601888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program