Provider Demographics
NPI:1669901286
Name:BERRYHILL, JEREME DEWAYNE
Entity type:Individual
Prefix:DR
First Name:JEREME
Middle Name:DEWAYNE
Last Name:BERRYHILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15500 BAYLIS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-1538
Mailing Address - Country:US
Mailing Address - Phone:901-461-7221
Mailing Address - Fax:
Practice Address - Street 1:3150 CASE RD BLDG C
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-5552
Practice Address - Country:US
Practice Address - Phone:419-383-3504
Practice Address - Fax:419-383-6127
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-07
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1029971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program