Provider Demographics
NPI:1437458346
Name:MENDIETA, EDGAR Y (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:Y
Last Name:MENDIETA
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 1:3160 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1310
Mailing Address - Country:US
Mailing Address - Phone:614-230-0374
Mailing Address - Fax:
Practice Address - Street 1:3160 W BROAD ST # 2300374
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1310
Practice Address - Country:US
Practice Address - Phone:614-279-6481
Practice Address - Fax:614-279-0199
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0224301223X0400X
OH30.0224301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics