Healthcare Provider Details

I. General information

NPI: 1760802102
Provider Name (Legal Business Name): MERRITT PERIODONTICS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 EAST ELIZABETH STREET SUITE G5
FORT COLLINS CO
80524-4044
US

IV. Provider business mailing address

1120 EAST ELIZABETH STREET SUITE G5
FORT COLLINS CO
80524-4044
US

V. Phone/Fax

Practice location:
  • Phone: 970-221-5050
  • Fax: 970-221-5054
Mailing address:
  • Phone: 970-221-5050
  • Fax: 970-221-5054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8786
License Number StateCO

VIII. Authorized Official

Name: MS. JENNIFER R. MERRITT
Title or Position: OWNER
Credential: D.D.S.
Phone: 970-221-5050