Provider Demographics
NPI:1598171506
Name:MENDOZA, JACQUELINE LOPEZ (DDS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LOPEZ
Last Name:MENDOZA
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 1:1615 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7984
Mailing Address - Country:US
Mailing Address - Phone:231-745-4624
Mailing Address - Fax:231-745-5031
Practice Address - Street 1:11 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-7900
Practice Address - Country:US
Practice Address - Phone:231-834-9750
Practice Address - Fax:231-834-1459
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI290102136021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice