Provider Demographics
NPI:1639588635
Name:MENDOZA, MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MENDOZA
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:PSC 561 BOX 1877
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0019
Mailing Address - Country:US
Mailing Address - Phone:315-255-8500
Mailing Address - Fax:
Practice Address - Street 1:USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI
Practice Address - Street 2:1 MISUMI MACHI
Practice Address - City:IWAKUNI
Practice Address - State:YAMAGUCHI
Practice Address - Zip Code:7400025
Practice Address - Country:JP
Practice Address - Phone:315-255-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD101371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice