MEDICARE: MERRILL RANCH DENTAL COMPANY, P.C.

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	122300000X	Dentist	6458	AZ
2	1223G0001X	General Practice Dentistry	6458	AZ

General Provider Information

NPI Number	:	1568778538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERRILL RANCH DENTAL COMPANY, P.C.

Provider Business Mailing Address
First Line	:	4704 E SOUTHERN AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-2737
Country	:	US
Telephone Number	:	480-648-4037
Fax Number	:	480-696-5505

Provider Business Practice Location Address
First Line	:	4704 E SOUTHERN AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-2737
Country	:	US
Telephone Number	:	480-648-4037
Fax Number	:	480-696-5505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ERIC LYNN KERBS
Credential	:	DDS
Telephone Number	:	480-648-4037

Provider Enumeration Date	:	08/27/2010
Last Update Date	:	12/06/2013

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