Provider Demographics
NPI:1134609050
Name:MERRYMAN, ANDREA P
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:P
Last Name:MERRYMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 SKYLINE RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9427
Mailing Address - Country:US
Mailing Address - Phone:503-588-6560
Mailing Address - Fax:
Practice Address - Street 1:5135 SKYLINE RD SOUTH
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306
Practice Address - Country:US
Practice Address - Phone:503-588-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant