MEDICARE: MR. JOHN FREEMAN MERRILL L.D

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	122400000X	Denturist	5012	ME

General Provider Information

NPI Number	:	1548587819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN FREEMAN MERRILL L.D

Provider Business Mailing Address
First Line	:	PO BOX 107
Second Line	:
City	:	ETNA
State	:	ME
Zip	:	04434-0107
Country	:	US
Telephone Number	:	207-269-4570
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 STAGE RD
Second Line	:
City	:	ETNA
State	:	ME
Zip	:	04434
Country	:	US
Telephone Number	:	207-269-4570
Fax Number	:

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

Provider Enumeration Date	:	04/27/2010
Last Update Date	:	04/27/2010

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