Healthcare Provider Details

I. General information

NPI: 1104131978
Provider Name (Legal Business Name): JERRY POWELL MAY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2392 NW ESQUIRE DR
ROSEBURG OR
97471-1702
US

IV. Provider business mailing address

2392 NW ESQUIRE DR
ROSEBURG OR
97471-1702
US

V. Phone/Fax

Practice location:
  • Phone: 954-290-0959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9589
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: