Provider Demographics
NPI:1104023621
Name:MENDOZA, LOUIE BANTUGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LOUIE
Middle Name:BANTUGAN
Last Name:MENDOZA
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 1:296 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1402
Mailing Address - Country:US
Mailing Address - Phone:510-526-8311
Mailing Address - Fax:510-526-9323
Practice Address - Street 1:296 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94707-1402
Practice Address - Country:US
Practice Address - Phone:510-526-8311
Practice Address - Fax:510-526-9323
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA943307533OtherTAX ID