Healthcare Provider Details

I. General information

NPI: 1659575314
Provider Name (Legal Business Name): JILL MERRILL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N 87TH ST
MILWAUKEE WI
53226-3586
US

IV. Provider business mailing address

10000 W INNOVATION DR
MILWAUKEE WI
53226-4837
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5760
  • Fax:
Mailing address:
  • Phone: 414-456-5006
  • Fax: 414-456-6259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD11533
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6169
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: