Provider Demographics
NPI:1063638393
Name:MERRELL, JERRY D (DDS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:MERRELL
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 1:2028 VILLAGE LANE
Mailing Address - Street 2:#101
Mailing Address - City:SOLVANG
Mailing Address - State:CA
Mailing Address - Zip Code:93463
Mailing Address - Country:US
Mailing Address - Phone:805-688-1155
Mailing Address - Fax:805-686-2699
Practice Address - Street 1:2028 VILLAGE LANE
Practice Address - Street 2:#101
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463
Practice Address - Country:US
Practice Address - Phone:805-688-1155
Practice Address - Fax:805-686-2699
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118381223S0112X
CA564491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56449OtherSTATE OF CALIFORNIA