Provider Demographics
NPI:1295393742
Name:MERRELL, JACOB PAUL (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PAUL
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 1:1400 RIVERY BLVD APT 2101
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3031
Mailing Address - Country:US
Mailing Address - Phone:412-491-7552
Mailing Address - Fax:
Practice Address - Street 1:1405 E ELMS RD
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-2810
Practice Address - Country:US
Practice Address - Phone:254-519-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35095122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist