Provider Demographics
NPI:1609997675
Name:IMAGE DENTAL EAGLE LLC
Entity Type:Organization
Organization Name:IMAGE DENTAL EAGLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MERYHEW
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:970-328-1116
Mailing Address - Street 1:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-0576
Mailing Address - Country:US
Mailing Address - Phone:970-328-1116
Mailing Address - Fax:970-328-0524
Practice Address - Street 1:56 MARKET ST
Practice Address - Street 2:SUITE #5
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-328-1116
Practice Address - Fax:970-328-0524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty