Provider Demographics
NPI:1659575314
Name:MERRILL, JILL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4837
Mailing Address - Country:US
Mailing Address - Phone:414-456-5006
Mailing Address - Fax:414-456-6259
Practice Address - Street 1:840 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3586
Practice Address - Country:US
Practice Address - Phone:414-805-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115331223S0112X
WI61691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33815800Medicaid
WI33815800Medicaid