Provider Demographics
NPI:1477211860
Name:MENDOLLA, LEA (RDH)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:MENDOLLA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 S TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2615
Mailing Address - Country:US
Mailing Address - Phone:920-583-9051
Mailing Address - Fax:
Practice Address - Street 1:139 S TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2615
Practice Address - Country:US
Practice Address - Phone:920-583-9051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5201-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist