Provider Demographics
NPI:1336865476
Name:MENDOZA NICOLAS, MICHELLE MONSERRAT
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MONSERRAT
Last Name:MENDOZA NICOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1582 SW 172ND TER UNIT 407
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-4299
Mailing Address - Country:US
Mailing Address - Phone:503-884-5210
Mailing Address - Fax:
Practice Address - Street 1:1582 SW 172ND TER UNIT 407
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-4299
Practice Address - Country:US
Practice Address - Phone:503-884-5210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No124Q00000XDental ProvidersDental Hygienist