Provider Demographics
NPI:1902958069
Name:MERICLE, IVAN ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:ANDREW
Last Name:MERICLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12120 RUSTIC RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33635-9534
Mailing Address - Country:US
Mailing Address - Phone:440-225-9221
Mailing Address - Fax:
Practice Address - Street 1:2450 SUNSET POINT RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1516
Practice Address - Country:US
Practice Address - Phone:727-303-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-022572122300000X
FLDN18906122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist