Provider Demographics
NPI:1306908165
Name:MIRACLE, JERRY ERVIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ERVIN
Last Name:MIRACLE
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 1:1329 PATTERSON ST
Mailing Address - Street 2:PO BOX 949
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-4349
Mailing Address - Country:US
Mailing Address - Phone:704-289-1993
Mailing Address - Fax:
Practice Address - Street 1:1329 PATTERSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4349
Practice Address - Country:US
Practice Address - Phone:704-289-1993
Practice Address - Fax:704-226-1743
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice