Provider Demographics
NPI:1942531447
Name:MENDOZA, BALTAZAR (RDA)
Entity Type:Individual
Prefix:
First Name:BALTAZAR
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7691 EL CHACO DR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1807
Mailing Address - Country:US
Mailing Address - Phone:562-912-8307
Mailing Address - Fax:
Practice Address - Street 1:7691 EL CHACO DRIVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620
Practice Address - Country:US
Practice Address - Phone:562-912-8307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68051126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68051OtherCALIFORNIA DENTAL BOARD