Provider Demographics
NPI:1821027749
Name:ANDEMICHAEL, MERON NEGASH (DDS)
Entity Type:Individual
Prefix:DR
First Name:MERON
Middle Name:NEGASH
Last Name:ANDEMICHAEL
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:PO BOX 453
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-0453
Mailing Address - Country:US
Mailing Address - Phone:910-984-1556
Mailing Address - Fax:910-984-1557
Practice Address - Street 1:80 AUTUMN FERN TRAIL
Practice Address - Street 2:EAST CAROLINA UNIVERSITY SCHOOL OF DENTISTRY
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546
Practice Address - Country:US
Practice Address - Phone:252-737-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5699122300000X
NC9628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ709644Medicaid