Provider Demographics
NPI:1194455352
Name:MENDOZA, FABIAN A (DDS)
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:A
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 1:15402 OAKLAWN PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-1512
Mailing Address - Country:US
Mailing Address - Phone:832-982-9068
Mailing Address - Fax:
Practice Address - Street 1:5505 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1601
Practice Address - Country:US
Practice Address - Phone:505-843-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5630122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist