Provider Demographics
NPI:1801278973
Name:NORVELL, JERRICA (DMD)
Entity type:Individual
Prefix:
First Name:JERRICA
Middle Name:
Last Name:NORVELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 BRYANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-7063
Mailing Address - Country:US
Mailing Address - Phone:606-706-0408
Mailing Address - Fax:
Practice Address - Street 1:821 S HIGHWAY 25 W
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1918
Practice Address - Country:US
Practice Address - Phone:606-549-0374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY96071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice