Active NPI
Mervin Lee Ellstrom, DDS
- Dentist
- Moreno Valley, CA
National Provider Identifier
1083052138
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 024928
- Practice address
- 12900 Perris Blvd
Suite 101
Moreno Valley, CA 92553-4135 - Phone
- (951) 242-3431
- Fax
- (951) 242-7570
- NPI assigned
- Jun 11, 2013
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 024928 | CA | Primary |
Addresses
Primary practice location
12900 Perris Blvd
Suite 101
Moreno Valley, CA 92553-4135
Mailing address
12900 Perris Blvd
Suite 101
Moreno Valley, CA 92553-4135
Phone (951) 242-3431
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 024928 | CA | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mervin L. Ellstrom DDS, Inc | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- General Practice Dentistry
- Moreno Valley, CA
- NPI 1912121781
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1370908800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1370908800000",
"number": "1083052138",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12900 PERRIS BLVD",
"address_2": "SUITE 101",
"city": "MORENO VALLEY",
"state": "CA",
"postal_code": "925534135",
"telephone_number": "951-242-3431",
"fax_number": "951-242-7570"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12900 PERRIS BLVD",
"address_2": "SUITE 101",
"city": "MORENO VALLEY",
"state": "CA",
"postal_code": "925534135",
"telephone_number": "951-242-3431",
"fax_number": "951-242-7570"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLSTROM",
"first_name": "MERVIN",
"middle_name": "LEE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2013-06-11",
"last_updated": "2013-06-11",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "024928",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Moreno Valley, CA
- Elite Health Providers
- Elizabeth Tong DDS Corp.
- Ellee Residential Care 5 LLC
- Cheryle Ann Eller
- Jeanita Ellington
- Eluxe Express
- Emergency Medicine Physician Partners of Riverside County, Inc
- Emergency Medicine Physicians of Riverside County, Inc.
- Emergency Physicians Medical Group, Inc
- Empathy Elderly Care Corp.
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.