Provider Demographics
NPI:1629665393
Name:MENDIETA, CARLENE ANN
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:ANN
Last Name:MENDIETA
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 1:19500 7TH ST E
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-7201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 5TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2919
Practice Address - Country:US
Practice Address - Phone:415-929-6501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347411223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics