MEDICARE: DR. SCOTT J MERKELSON D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4583	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4583	OTHER	CT	LICENSE NUMBER

General Provider Information

NPI Number	:	1023162955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT J MERKELSON D.M.D.

Provider Business Mailing Address
First Line	:	34 JEROME AVE
Second Line	:	SUITE 112
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2463
Country	:	US
Telephone Number	:	860-242-0590
Fax Number	:	860-242-0873

Provider Business Practice Location Address
First Line	:	34 JEROME AVE
Second Line	:	SUITE 112
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-2463
Country	:	US
Telephone Number	:	860-242-0590
Fax Number	:	860-242-0873

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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