Provider Demographics
NPI:1386380764
Name:MCDONIELL, JEREMY DYLAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:DYLAN
Last Name:MCDONIELL
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 1:506 N SECTION ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-2616
Mailing Address - Country:US
Mailing Address - Phone:251-928-1645
Mailing Address - Fax:
Practice Address - Street 1:506 N SECTION ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2616
Practice Address - Country:US
Practice Address - Phone:251-928-1645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007296-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice