Provider Demographics
NPI:1821735408
Name:MENDEZ, JESUS ANTONIO (DMD)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ANTONIO
Last Name:MENDEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HAVILAND ST APT 33
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-2651
Mailing Address - Country:US
Mailing Address - Phone:786-521-5494
Mailing Address - Fax:
Practice Address - Street 1:18 HAVILAND ST APT 33
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-2651
Practice Address - Country:US
Practice Address - Phone:786-521-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program