Provider Demographics
NPI:1508169251
Name:MARK MENDIOLA, D.D.S., P.C.
Entity Type:Organization
Organization Name:MARK MENDIOLA, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-210-8049
Mailing Address - Street 1:345 N LASALLE ST
Mailing Address - Street 2:UNIT 4407
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6101
Mailing Address - Country:US
Mailing Address - Phone:248-210-8049
Mailing Address - Fax:
Practice Address - Street 1:5050 S KEDZIE AVE
Practice Address - Street 2:UNIT A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-3009
Practice Address - Country:US
Practice Address - Phone:773-778-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0267721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty