Provider Demographics
NPI:1154629970
Name:MENDOZA, MARIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 CASCADE CT W
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-4437
Mailing Address - Country:US
Mailing Address - Phone:503-867-1668
Mailing Address - Fax:
Practice Address - Street 1:847 CASCADE CT W
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-4437
Practice Address - Country:US
Practice Address - Phone:503-867-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA602171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice