Provider Demographics
NPI:1972516607
Name:MERRELL, MICHAEL ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
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 1:1183 SUMMERS DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5224
Mailing Address - Country:US
Mailing Address - Phone:208-356-9097
Mailing Address - Fax:208-359-2021
Practice Address - Street 1:1183 SUMMERS DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5224
Practice Address - Country:US
Practice Address - Phone:208-356-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3211122300000X
IDD321122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000980900Medicaid