Provider Demographics
NPI:1538633946
Name:MEREDITH, ISAAC ROBERT (DT)
Entity Type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:ROBERT
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3532
Mailing Address - Country:US
Mailing Address - Phone:612-232-8958
Mailing Address - Fax:
Practice Address - Street 1:1016 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3510
Practice Address - Country:US
Practice Address - Phone:320-235-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT97125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist