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General NPI Number Information
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NPI Number | 1104089903
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Entity Type | Individual
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Provider Name | JACOB DYLAN MERRYMAN DDS
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Gender | Male
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 07/30/2009
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Provider Practice Location Address
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Address Line | 453 DIXON RD SUITE #3
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City | QUEENSBURY
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State | NY
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Zip | 12804-1964
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Country | US
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Telephone | 518-793-3553
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Fax |
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Provider Business Mailing Address
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Address Line | 24 PEARL ST APT #1
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City | SCHUYLERVILLE
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State | NY
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Zip | 12871-1407
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Country | US
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Telephone | 518-695-4692
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 50 054420
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License Number State | NY
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