Provider Demographics
NPI:1619150802
Name:MERRIAM, BRUCE ARTHUR (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ARTHUR
Last Name:MERRIAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4800
Mailing Address - Country:US
Mailing Address - Phone:631-475-3400
Mailing Address - Fax:631-475-3465
Practice Address - Street 1:250 PATCHOGUE YAPHANK RD
Practice Address - Street 2:SUITE 9
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4800
Practice Address - Country:US
Practice Address - Phone:631-475-3400
Practice Address - Fax:631-475-3465
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028780-11223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics