Provider Demographics
NPI:1114536653
Name:MONDRAGON, EDUARDO DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:DAVID
Last Name:MONDRAGON
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 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-350-4606
Mailing Address - Fax:970-350-4645
Practice Address - Street 1:1006 A SREET
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631
Practice Address - Country:US
Practice Address - Phone:970-352-0048
Practice Address - Fax:970-352-1120
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61085473122300000X
CO2045531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice