Provider Demographics
NPI:1477944494
Name:MONDOCK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MONDOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:15697-1112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 S 5TH ST
Practice Address - Street 2:
Practice Address - City:YOUNGWOOD
Practice Address - State:PA
Practice Address - Zip Code:15697-1112
Practice Address - Country:US
Practice Address - Phone:724-925-6816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026883L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist