Provider Demographics
NPI:1144336959
Name:MERRILL, SANDRA (DMD,MS,PA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MERRILL
Suffix:
Gender:F
Credentials:DMD,MS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 INDIAN TRAIL ROAD N
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079
Mailing Address - Country:US
Mailing Address - Phone:704-684-0195
Mailing Address - Fax:704-684-0198
Practice Address - Street 1:331 INDIAN TRAIL RD., N
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079
Practice Address - Country:US
Practice Address - Phone:704-684-0195
Practice Address - Fax:704-684-0198
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC899013JMedicaid