Provider Demographics
NPI:1629672274
Name:OLIVERA MENDEZ, SUCELLE
Entity Type:Individual
Prefix:
First Name:SUCELLE
Middle Name:
Last Name:OLIVERA MENDEZ
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 1:8384 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-2619
Mailing Address - Country:US
Mailing Address - Phone:239-738-9126
Mailing Address - Fax:
Practice Address - Street 1:18990 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4737
Practice Address - Country:US
Practice Address - Phone:239-482-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH26631124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist