Provider Demographics
NPI:1700298387
Name:MERVAU, JESSICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:MERVAU
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 1:312 CATRON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1806
Mailing Address - Country:US
Mailing Address - Phone:505-986-0606
Mailing Address - Fax:
Practice Address - Street 1:312 CATRON ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1806
Practice Address - Country:US
Practice Address - Phone:505-986-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100086915122300000X
CO00202605122300000X
390200000X
NMDD5384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program