1760802102 NPI number — MERRITT PERIODONTICS P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760802102 NPI number — MERRITT PERIODONTICS P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRITT PERIODONTICS P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760802102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 EAST ELIZABETH STREET
Provider Second Line Business Mailing Address:
SUITE G5
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80524-4044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-221-5050
Provider Business Mailing Address Fax Number:
970-221-5054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 EAST ELIZABETH STREET
Provider Second Line Business Practice Location Address:
SUITE G5
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80524-4044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-221-5050
Provider Business Practice Location Address Fax Number:
970-221-5054
Provider Enumeration Date:
04/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MERRITT
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-221-5050

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  8786 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9625 . This is a "COLORADO DENTAL LICENSE DR. MERRITT" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 8786 . This is a "COLORADO DENTAL LICENSE DR. JOHNSON" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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