Provider Demographics
NPI:1487104188
Name:MARCUS MERCER
Entity type:Organization
Organization Name:MARCUS MERCER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-373-6309
Mailing Address - Street 1:5526 E LAKE DR
Mailing Address - Street 2:A
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2691
Mailing Address - Country:US
Mailing Address - Phone:630-373-6309
Mailing Address - Fax:
Practice Address - Street 1:5526 E LAKE DR
Practice Address - Street 2:A
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-2691
Practice Address - Country:US
Practice Address - Phone:630-373-6309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019018685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019018685OtherSTATE OF ILLINOIS