Healthcare Provider Details

I. General information

NPI: 1164528949
Provider Name (Legal Business Name): JESSE MURILLO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3458 NEELY RD
JB MDL NJ
08641
US

IV. Provider business mailing address

3458 NEELY RD
JB MDL NJ
08641-5312
US

V. Phone/Fax

Practice location:
  • Phone: 609-754-3786
  • Fax:
Mailing address:
  • Phone: 609-754-3786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number19325
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: