Provider Demographics
NPI:1174631071
Name:MELLERT, JAMES W (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:MELLERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 TORRANCE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5808
Mailing Address - Country:US
Mailing Address - Phone:310-543-1234
Mailing Address - Fax:310-543-8795
Practice Address - Street 1:3480 TORRANCE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5808
Practice Address - Country:US
Practice Address - Phone:310-543-1234
Practice Address - Fax:310-543-8795
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice