1568778538 NPI number — MERRILL RANCH DENTAL COMPANY, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568778538 NPI number — MERRILL RANCH DENTAL COMPANY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRILL RANCH DENTAL COMPANY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568778538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4704 E SOUTHERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85206-2737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-648-4037
Provider Business Mailing Address Fax Number:
480-696-5505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4704 E SOUTHERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-2737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-648-4037
Provider Business Practice Location Address Fax Number:
480-696-5505
Provider Enumeration Date:
08/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KERBS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-648-4037

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  6458 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 6458 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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