Provider Demographics
NPI:1578788428
Name:PAEZ DE MENDOZA, CARMEN YAMILY
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:YAMILY
Last Name:PAEZ DE MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 RICHLAND WAY
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9145
Mailing Address - Country:US
Mailing Address - Phone:317-818-0832
Mailing Address - Fax:
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5211
Practice Address - Country:US
Practice Address - Phone:317-278-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010273A1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics