Provider Demographics
NPI:1104962893
Name:MENDELSOHN, IRA (DDS)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:
Last Name:MENDELSOHN
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 1:8003 LAGOON DR
Mailing Address - Street 2:
Mailing Address - City:MARGATE CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08402-1614
Mailing Address - Country:US
Mailing Address - Phone:609-641-1065
Mailing Address - Fax:609-645-0162
Practice Address - Street 1:50 W BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-2645
Practice Address - Country:US
Practice Address - Phone:609-641-1065
Practice Address - Fax:609-645-0162
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI01124100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist