Provider Demographics
NPI:1407903032
Name:MENDIOLA, MARK ANTHONY MANUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK ANTHONY
Middle Name:MANUEL
Last Name:MENDIOLA
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 1:345 N LA SALLE DR
Mailing Address - Street 2:UNIT 4407
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-6101
Mailing Address - Country:US
Mailing Address - Phone:248-210-8049
Mailing Address - Fax:
Practice Address - Street 1:2001 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2486
Practice Address - Country:US
Practice Address - Phone:773-484-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist