Healthcare Provider Details

I. General information

NPI: 1366124935
Provider Name (Legal Business Name): MITCHELL MERRILL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6990 QUINN ST BLDG 2356
FORT CARSON CO
80913-4450
US

IV. Provider business mailing address

1667 COCHRANE CIR BLDG 7495
FORT CARSON CO
80913-4603
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00205674
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: