Provider Demographics
NPI:1023546629
Name:10439 E US HIGHWAY 36 DENTAL, LLC
Entity type:Organization
Organization Name:10439 E US HIGHWAY 36 DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:ALLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-288-5384
Mailing Address - Street 1:2857 HULL RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-8239
Mailing Address - Country:US
Mailing Address - Phone:252-512-0300
Mailing Address - Fax:
Practice Address - Street 1:10439 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:317-300-0577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty