Healthcare Provider Details

I. General information

NPI: 1689879603
Provider Name (Legal Business Name): DONALD RUSSELL MERRYFIELD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 VARNUM ST NE #006 DE PAUL BLDG PROVIDENCE HOSPITAL
WASHINGTON DC
20017
US

IV. Provider business mailing address

10545 TODDS CORNER RD
EASTON MD
21601-5437
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-7103
  • Fax: 202-269-7100
Mailing address:
  • Phone: 410-763-8432
  • Fax: 410-763-8432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDEN2274
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4423
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: