1265500565 NPI number — THE MAIN STREET DENTISTS INC

Table of content: (NPI 1265500565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265500565 NPI number — THE MAIN STREET DENTISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MAIN STREET DENTISTS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JON DAVID MEHR DDS & MARTHA BRIDGES MEHR DDS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265500565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 W MAGNOLIA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-787-4800
Provider Business Mailing Address Fax Number:
352-787-9091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 W MAGNOLIA STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-787-4800
Provider Business Practice Location Address Fax Number:
352-787-9091
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEHR
Authorized Official First Name:
JON
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
DR & PRESIDENT OF CORPORATION
Authorized Official Telephone Number:
352-787-4800

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN0014763 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: DN0014896 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1364448 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36839 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 749700 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36838 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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