Healthcare Provider Details

I. General information

NPI: 1003882184
Provider Name (Legal Business Name): KENNETH A MERTZ JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 UNIVERSITY BLVD.
JACKSONVILLE FL
32216
US

IV. Provider business mailing address

900 UNIVERSITY BLVD N MC - 75
JACKSONVILLE FL
32211-9230
US

V. Phone/Fax

Practice location:
  • Phone: 904-253-1240
  • Fax: 904-727-6548
Mailing address:
  • Phone: 904-253-2062
  • Fax: 904-253-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN15901
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN15901
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: