Provider Demographics
NPI:1649878968
Name:MENDOZA, ROSALYN (RDA)
Entity type:Individual
Prefix:
First Name:ROSALYN
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18264 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3060
Mailing Address - Country:US
Mailing Address - Phone:626-536-2249
Mailing Address - Fax:
Practice Address - Street 1:18264 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3060
Practice Address - Country:US
Practice Address - Phone:626-536-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87846126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA87846Medicaid