Provider Demographics
NPI:1851623995
Name:MELLARD, MARY V (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:V
Last Name:MELLARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24200 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?:No
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist