Provider Demographics
NPI:1245252659
Name:MUNDENAR, MICHAEL J (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:MUNDENAR
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 1:606 FLORAL VALE BLVD
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-5528
Mailing Address - Country:US
Mailing Address - Phone:215-504-0600
Mailing Address - Fax:215-504-0951
Practice Address - Street 1:606 FLORAL VALE BLVD
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-5528
Practice Address - Country:US
Practice Address - Phone:215-504-0600
Practice Address - Fax:215-504-0951
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-024081-L1223P0106X
PADS024081L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00042493000OtherKEYSTONE HEALTH PLAN EAST
PA166433OtherHIGHMARK/BLUE SHIELD
PAWA190229655OtherMEDICARE RR #
PA68626OtherAETNA ID #
PAWA190229655OtherMEDICARE RR #
PAU09178Medicare UPIN