Provider Demographics
NPI:1891140075
Name:MARCUSSEN, MERISSA VELMA RICHTER (DDS)
Entity Type:Individual
Prefix:
First Name:MERISSA
Middle Name:VELMA RICHTER
Last Name:MARCUSSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MERISSA
Other - Middle Name:VELMA
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1121 VAGABOND CT N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-2572
Mailing Address - Country:US
Mailing Address - Phone:612-247-2314
Mailing Address - Fax:
Practice Address - Street 1:4180 DEAN LAKES BLVD
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2851
Practice Address - Country:US
Practice Address - Phone:952-233-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND136931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice