Provider Demographics
NPI:1811156722
Name:MERIDIAN PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:MERIDIAN PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-288-2719
Mailing Address - Street 1:1550 E HERITAGE PARK ST STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5886
Mailing Address - Country:US
Mailing Address - Phone:208-288-2719
Mailing Address - Fax:208-288-2579
Practice Address - Street 1:1550 E HERITAGE PARK ST STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5886
Practice Address - Country:US
Practice Address - Phone:208-288-2719
Practice Address - Fax:208-288-2579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3592-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806274800Medicaid