Provider Demographics
NPI:1265632749
Name:MENDOLA, VINCENT M (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:M
Last Name:MENDOLA
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 1:9998 S HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:NY
Mailing Address - Zip Code:14025-9755
Mailing Address - Country:US
Mailing Address - Phone:716-941-5157
Mailing Address - Fax:
Practice Address - Street 1:9998 S HILL RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:NY
Practice Address - Zip Code:14025-9755
Practice Address - Country:US
Practice Address - Phone:716-941-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0285401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00411798Medicaid