Provider Demographics
NPI:1316974454
Name:MERRELL, PHILLIP (DDS)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MERRELL
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:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-8950
Practice Address - Street 1:2155 WESTER STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-929-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP1561223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB64366FMedicaid
CAZZZ84563ZMedicare ID - Type UnspecifiedGROUP ID