MEDICARE: MERIT DENTISTRY OF INDIANA, PC

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	:	1811311525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIT DENTISTRY OF INDIANA, PC

Provider Business Mailing Address
First Line	:	1015 PROFESSIONAL BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-8010
Country	:	US
Telephone Number	:	812-437-1015
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 PROFESSIONAL BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47714-8010
Country	:	US
Telephone Number	:	812-437-1015
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JEFFREY MOOS
Credential	:	DDS
Telephone Number	:	715-318-2304

Provider Enumeration Date	:	02/17/2014
Last Update Date	:	02/17/2014

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