MEDICARE: DR. JANTRAVEUS MERRITT DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30710	TX

General Provider Information

NPI Number	:	1114319662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANTRAVEUS MERRITT DMD

Provider Business Mailing Address
First Line	:	1354 W 43RD ST
Second Line	:	C
City	:	HOUSTON
State	:	TX
Zip	:	77018-4206
Country	:	US
Telephone Number	:	713-481-6864
Fax Number	:

Provider Business Practice Location Address
First Line	:	1354 W 43RD ST
Second Line	:	C
City	:	HOUSTON
State	:	TX
Zip	:	77018-4206
Country	:	US
Telephone Number	:	713-481-6864
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2015
Last Update Date	:	02/20/2015

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