=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710073762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBRA SUE MCNAIR-MERTES RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3540C N 126TH ST
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-790-9559
-----------------------------------------------------
Fax | 262-790-9609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 NEEDHAM ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02461-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-964-6681
-----------------------------------------------------
Fax | 617-630-0141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 4666
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------