Healthcare Provider Details

I. General information

NPI: 1629071618
Provider Name (Legal Business Name): PENNY MERICLE D.M.D, M.S.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WELLES ST
FORTY FORT PA
18704-4968
US

IV. Provider business mailing address

190 WELLES ST
FORTY FORT PA
18704-4968
US

V. Phone/Fax

Practice location:
  • Phone: 570-287-8700
  • Fax:
Mailing address:
  • Phone: 570-287-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS025005L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: