Provider Demographics
NPI:1609108307
Name:MERTZ FAMILY DENTISTRY
Entity Type:Organization
Organization Name:MERTZ FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:MERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-678-1111
Mailing Address - Street 1:1950 TERRY STREET
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-678-1111
Mailing Address - Fax:
Practice Address - Street 1:1950 TERRY ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1835
Practice Address - Country:US
Practice Address - Phone:303-678-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10 81501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty