MEDICARE: MS. MERRILYN PETERSON PRUCHA RDH

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	124Q00000X	Dental Hygienist	0402002559	VA

General Provider Information

NPI Number	:	1083694491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MERRILYN PETERSON PRUCHA RDH

Provider Business Mailing Address
First Line	:	1901 EASTOVER CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8911
Country	:	US
Telephone Number	:	757-314-7190
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 TOMCAT BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23460-2218
Country	:	US
Telephone Number	:	757-314-7190
Fax Number	:

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	07/08/2007

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