Provider Demographics
NPI:1740340256
Name:MYROM, JEREMY (DR DENTIST)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:MYROM
Suffix:
Gender:M
Credentials:DR DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:1616 N FRANKLIN ST
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334
Mailing Address - Country:US
Mailing Address - Phone:320-634-3556
Mailing Address - Fax:320-634-3567
Practice Address - Street 1:1616 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334
Practice Address - Country:US
Practice Address - Phone:320-634-3556
Practice Address - Fax:320-634-3567
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice