Provider Demographics
NPI:1245751924
Name:JUSTIN MERCER DENTAL CORPORATION
Entity Type:Organization
Organization Name:JUSTIN MERCER DENTAL CORPORATION
Other - Org Name:PROMENADE DENTISTS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-703-1012
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:2710 VIA DE LA VALLE
Practice Address - Street 2:SUITE B250
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014
Practice Address - Country:US
Practice Address - Phone:858-703-1012
Practice Address - Fax:858-224-0955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty