Provider Demographics
NPI:1255477592
Name:GUY W MENDIVIL DDS PROFESSIONAL DENTAL CORP
Entity Type:Organization
Organization Name:GUY W MENDIVIL DDS PROFESSIONAL DENTAL CORP
Other - Org Name:BAKERSFIELD ORTHODONTIC DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MENDIVIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-323-5910
Mailing Address - Street 1:515 W COLUMBUS ST STE AB
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-5846
Mailing Address - Country:US
Mailing Address - Phone:661-323-5910
Mailing Address - Fax:
Practice Address - Street 1:515 W COLUMBUS ST STE AB
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5846
Practice Address - Country:US
Practice Address - Phone:661-323-5910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD297371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9391401OtherDENTI-CAL
CA170062OtherCGP