Provider Demographics
NPI:1619967379
Name:MENDIETA, JORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:MENDIETA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 BROADWAY
Mailing Address - Street 2:#16-G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5028
Mailing Address - Country:US
Mailing Address - Phone:212-496-5090
Mailing Address - Fax:
Practice Address - Street 1:CAS/MILBANK MEDICAL GROUP
Practice Address - Street 2:14-32 WEST 118 STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1904
Practice Address - Country:US
Practice Address - Phone:212-369-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043265-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice