Provider Demographics
NPI:1902903669
Name:KUNUKKASSERIL, MERIN
Entity Type:Individual
Prefix:
First Name:MERIN
Middle Name:
Last Name:KUNUKKASSERIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MERIN
Other - Middle Name:K
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3885
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:760-414-3885
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist