Provider Demographics
NPI:1336173814
Name:MENDIVE, STEVEN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:R
Last Name:MENDIVE
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:PO BOX 3002
Mailing Address - Street 2:206 CALLAHAN RD SUITE 1
Mailing Address - City:TROY
Mailing Address - State:MT
Mailing Address - Zip Code:59935-3002
Mailing Address - Country:US
Mailing Address - Phone:406-295-4120
Mailing Address - Fax:406-295-9550
Practice Address - Street 1:206 CALLAHAN AVENUE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MT
Practice Address - Zip Code:59935
Practice Address - Country:US
Practice Address - Phone:406-295-4120
Practice Address - Fax:406-295-9550
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT121290Medicaid