Provider Demographics
NPI:1942409222
Name:JAMES W. MELLERT D.D.S., APC
Entity Type:Organization
Organization Name:JAMES W. MELLERT D.D.S., APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-543-1234
Mailing Address - Street 1:21350 HAWTHORNE BLVD
Mailing Address - Street 2:STE 175
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5605
Mailing Address - Country:US
Mailing Address - Phone:310-543-1234
Mailing Address - Fax:310-543-8795
Practice Address - Street 1:21350 HAWTHORNE BLVD
Practice Address - Street 2:STE 175
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5605
Practice Address - Country:US
Practice Address - Phone:310-543-1234
Practice Address - Fax:310-543-8795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty