Provider Demographics
NPI:1104089903
Name:MERRYMAN, JACOB DYLAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DYLAN
Last Name:MERRYMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PEARL ST
Mailing Address - Street 2:APT #1
Mailing Address - City:SCHUYLERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12871-1407
Mailing Address - Country:US
Mailing Address - Phone:518-695-4692
Mailing Address - Fax:
Practice Address - Street 1:453 DIXON RD
Practice Address - Street 2:SUITE #3
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1964
Practice Address - Country:US
Practice Address - Phone:518-793-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY50 054420122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program