MEDICARE: MECKLER DENTAL PROVIDERS (AVON), INC.

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

General Provider Information

NPI Number	:	1053778092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLER DENTAL PROVIDERS (AVON), INC.

Provider Business Mailing Address
First Line	:	7160 DALLAS PKWY STE 400
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-7111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	36050 DETROIT RD STE T
Second Line	:
City	:	AVON
State	:	OH
Zip	:	44011-1685
Country	:	US
Telephone Number	:	440-934-0147
Fax Number	:

Authorized Official
Title or Position	:	MANAGER CREDENTIALING
Name	:	RACHEL NITTINGER
Credential	:
Telephone Number	:	972-755-0816

Provider Enumeration Date	:	01/21/2016
Last Update Date	:	03/20/2018

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