Provider Demographics
NPI:1801981865
Name:BAZILIO, MERNEATHA (DDS)
Entity type:Individual
Prefix:DR
First Name:MERNEATHA
Middle Name:
Last Name:BAZILIO
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 1:6020 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-3413
Mailing Address - Country:US
Mailing Address - Phone:317-545-1044
Mailing Address - Fax:317-545-1055
Practice Address - Street 1:6020 E 46TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-3413
Practice Address - Country:US
Practice Address - Phone:317-545-1044
Practice Address - Fax:317-545-1055
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120088901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100259200BMedicaid
IN100259200AMedicaid
IN464717OtherUNITED CONCORDIA