Healthcare Provider Details

I. General information

NPI: 1780725952
Provider Name (Legal Business Name): DAVID DETLEF MENTZ D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 E FOREST AVE
NEENAH WI
54956-2710
US

IV. Provider business mailing address

456 PLEASANT CT
NEENAH WI
54956-1926
US

V. Phone/Fax

Practice location:
  • Phone: 920-722-0530
  • Fax: 920-722-5210
Mailing address:
  • Phone: 920-720-0925
  • Fax: 920-720-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3488
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: