Provider Demographics
NPI:1629028998
Name:MERRIAM, PHYLLIS BETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:BETH
Last Name:MERRIAM
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 1:309 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2923
Mailing Address - Country:US
Mailing Address - Phone:516-316-2543
Mailing Address - Fax:515-569-4277
Practice Address - Street 1:7407 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7433
Practice Address - Country:US
Practice Address - Phone:718-386-2655
Practice Address - Fax:718-497-1243
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist