Provider Demographics
NPI:1407801939
Name:MERRIMAN, TOBY O (DMD)
Entity Type:Individual
Prefix:DR
First Name:TOBY
Middle Name:O
Last Name:MERRIMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E HERITAGE PARK ST
Mailing Address - Street 2:STE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5886
Mailing Address - Country:US
Mailing Address - Phone:208-288-2719
Mailing Address - Fax:208-288-2579
Practice Address - Street 1:1550 E HERITAGE PARK ST
Practice Address - Street 2:STE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5886
Practice Address - Country:US
Practice Address - Phone:208-288-2719
Practice Address - Fax:208-288-2579
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD35921223P0221X
IDD-3592-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-3592-PDOtherSTATE DENTAL LICENSE
ID806274800Medicaid