Provider Demographics
NPI:1235580747
Name:MENDIOLA, JENNE
Entity Type:Individual
Prefix:
First Name:JENNE
Middle Name:
Last Name:MENDIOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG #9440 BATTALION AVENUE
Mailing Address - Street 2:FAIRBANKS DENTAL CLINIC
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-288-7848
Mailing Address - Fax:
Practice Address - Street 1:BLDG #9440 BATTALION AVENUE
Practice Address - Street 2:FAIRBANKS DENTAL CLINIC
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9231124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist