Provider Demographics
NPI:1790746311
Name:MONDLICK, JOSHUA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:A
Last Name:MONDLICK
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 1:8671 W UNION HILLS DR
Mailing Address - Street 2:SUITE 501
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-7005
Mailing Address - Country:US
Mailing Address - Phone:623-583-3960
Mailing Address - Fax:
Practice Address - Street 1:8671 W UNION HILLS DR
Practice Address - Street 2:SUITE 501
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-7005
Practice Address - Country:US
Practice Address - Phone:623-583-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-026230122300000X
AZD62601223P0300X
NY053711-11223P0300X
TX284401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ877657Medicaid