Provider Demographics
NPI:1245672716
Name:MEHANZEL, HAILU SOLOMON (DMD)
Entity type:Individual
Prefix:
First Name:HAILU
Middle Name:SOLOMON
Last Name:MEHANZEL
Suffix:
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 1:7210 MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3339
Mailing Address - Country:US
Mailing Address - Phone:209-373-2800
Mailing Address - Fax:209-373-2878
Practice Address - Street 1:1031 WATERLOO RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4256
Practice Address - Country:US
Practice Address - Phone:209-940-5600
Practice Address - Fax:209-940-5065
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice