Provider Demographics
NPI:1245506443
Name:MENDOZA, CAMILLE S (RDH)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:S
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:S
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDH
Mailing Address - Street 1:620 SE KINKADE RD
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-2000
Mailing Address - Country:US
Mailing Address - Phone:541-325-2995
Mailing Address - Fax:
Practice Address - Street 1:620 SE KINKADE RD
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-2000
Practice Address - Country:US
Practice Address - Phone:541-325-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-01
Last Update Date:2012-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3136124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist