Provider Demographics
NPI:1083052138
Name:ELLSTROM, MERVIN LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MERVIN
Middle Name:LEE
Last Name:ELLSTROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 PERRIS BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4135
Mailing Address - Country:US
Mailing Address - Phone:951-242-3431
Mailing Address - Fax:951-242-7570
Practice Address - Street 1:12900 PERRIS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4135
Practice Address - Country:US
Practice Address - Phone:951-242-3431
Practice Address - Fax:951-242-7570
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA024928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist