Healthcare Provider Details

I. General information

NPI: 1780653675
Provider Name (Legal Business Name): MERRIT FUSSELMAN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14333 KINSMAN RD
BURTON OH
44021-9432
US

IV. Provider business mailing address

14333 KINSMAN RD
BURTON OH
44021-9432
US

V. Phone/Fax

Practice location:
  • Phone: 440-834-0003
  • Fax:
Mailing address:
  • Phone: 440-834-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number18850
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: