Provider Demographics
NPI:1043357288
Name:MELLARD, JAMES RANDALL (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RANDALL
Last Name:MELLARD
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24200 W IH 10
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1145
Mailing Address - Country:US
Mailing Address - Phone:210-687-1133
Mailing Address - Fax:210-687-1132
Practice Address - Street 1:24200 W IH 10
Practice Address - Street 2:SUITE 112
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1145
Practice Address - Country:US
Practice Address - Phone:210-687-1133
Practice Address - Fax:210-687-1132
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics