Provider Demographics
NPI:1568700912
Name:MABANGLO-SAMSON, BERNADETTE MENDOZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:MENDOZA
Last Name:MABANGLO-SAMSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11061 HULL STREET RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3255
Mailing Address - Country:US
Mailing Address - Phone:804-745-0666
Mailing Address - Fax:804-675-0938
Practice Address - Street 1:11061 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3255
Practice Address - Country:US
Practice Address - Phone:804-745-0666
Practice Address - Fax:804-675-0938
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014138391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice