Provider Demographics
NPI:1912121781
Name:MERVIN L. ELLSTROM DDS, INC
Entity Type:Organization
Organization Name:MERVIN L. ELLSTROM DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-242-3431
Mailing Address - Street 1:12900 PERRIS BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4135
Mailing Address - Country:US
Mailing Address - Phone:951-242-3431
Mailing Address - Fax:951-242-7570
Practice Address - Street 1:12900 PERRIS BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4135
Practice Address - Country:US
Practice Address - Phone:951-242-3431
Practice Address - Fax:951-242-7570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA249281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty