Provider Demographics
NPI:1003882184
Name:MERTZ, KENNETH A JR (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:MERTZ
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 UNIVERSITY BLVD N
Mailing Address - Street 2:MC - 75
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-9230
Mailing Address - Country:US
Mailing Address - Phone:904-253-2062
Mailing Address - Fax:904-253-1942
Practice Address - Street 1:1722 UNIVERSITY BLVD.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216
Practice Address - Country:US
Practice Address - Phone:904-253-1240
Practice Address - Fax:904-727-6548
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159011223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA801488195AMedicaid
FL075717900Medicaid
FL0757179-00Medicaid