Provider Demographics
NPI:1912004870
Name:MENDELOVITZ, PHILIP M (DDS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:MENDELOVITZ
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 1:100 UCLA MEDICAL PLZ
Mailing Address - Street 2:SUITE 445
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6970
Mailing Address - Country:US
Mailing Address - Phone:310-208-1161
Mailing Address - Fax:310-208-3288
Practice Address - Street 1:100 UCLA MEDICAL PLZ
Practice Address - Street 2:SUITE 445
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-6970
Practice Address - Country:US
Practice Address - Phone:310-208-1161
Practice Address - Fax:310-208-3288
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4377824OtherI.D.#