Provider Demographics
NPI:1740791524
Name:MERIT DENTAL INC.
Entity Type:Organization
Organization Name:MERIT DENTAL INC.
Other - Org Name:MIDWEST DENTAL FREEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRION-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-598-2311
Mailing Address - Street 1:680 HEHLI WAY
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1639
Mailing Address - Country:US
Mailing Address - Phone:715-598-2311
Mailing Address - Fax:715-350-6855
Practice Address - Street 1:421 MARKET ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:PA
Practice Address - Zip Code:16229-1121
Practice Address - Country:US
Practice Address - Phone:724-295-5125
Practice Address - Fax:724-295-5126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3139-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty