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General NPI Number Information
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NPI Number | 1700298387
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Entity Type | Individual
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Provider Name | JESSICA MERVAU DDS
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Gender | Female
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 03/26/2021
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Provider Practice Location Address
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Address Line | 312 CATRON ST
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City | SANTA FE
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State | NM
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Zip | 87501-1806
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Country | US
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Telephone | 505-986-0606
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Fax |
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Provider Business Mailing Address
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Address Line | 312 CATRON ST
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City | SANTA FE
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State | NM
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Zip | 87501-1806
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Country | US
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Telephone | 505-986-0606
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 100086915
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License Number State | WI
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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 | 00202605
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License Number State | CO
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Taxonomy #3
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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 #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD5384
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License Number State | NM
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