Provider Demographics
NPI:1265500565
Name:THE MAIN STREET DENTISTS INC
Entity Type:Organization
Organization Name:THE MAIN STREET DENTISTS INC
Other - Org Name:JON DAVID MEHR DDS & MARTHA BRIDGES MEHR DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:DR & PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MEHR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:352-787-4800
Mailing Address - Street 1:606 W MAGNOLIA STREET
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:352-787-4800
Mailing Address - Fax:352-787-9091
Practice Address - Street 1:606 W MAGNOLIA STREET
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-787-4800
Practice Address - Fax:352-787-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0014763122300000X
FLDN0014896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1364448OtherUNITED CONCORDIA
36839OtherBLUE CROSS BLUE SHIELD
749700OtherUNITED CONCORDIA
36838OtherBLUE CROSS BLUE SHIELD