Provider Demographics
NPI:1467539015
Name:ISRAEL, MEREDITH COURTNEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEREDITH
Middle Name:COURTNEY
Last Name:ISRAEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 PINEHURST LN
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1965
Mailing Address - Country:US
Mailing Address - Phone:702-355-8057
Mailing Address - Fax:
Practice Address - Street 1:11885 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3474
Practice Address - Country:US
Practice Address - Phone:586-574-9800
Practice Address - Fax:248-547-2291
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018695122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI490276Medicaid