Provider Demographics
NPI:1740258482
Name:MERTZEL, JAMES EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EDWARD
Last Name:MERTZEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:E
Other - Last Name:MERTZEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:8120 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-2941
Mailing Address - Country:US
Mailing Address - Phone:818-352-3174
Mailing Address - Fax:818-352-0104
Practice Address - Street 1:8120 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SUNLAND
Practice Address - State:CA
Practice Address - Zip Code:91040-2941
Practice Address - Country:US
Practice Address - Phone:818-352-3174
Practice Address - Fax:818-352-0104
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB15092Medicaid