Provider Demographics
NPI:1740481167
Name:MONDRAGON, ROBERT JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:MONDRAGON
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 1:159 S MAIN
Mailing Address - Street 2:PO BOX 596
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251
Mailing Address - Country:US
Mailing Address - Phone:517-896-9346
Mailing Address - Fax:517-589-5154
Practice Address - Street 1:159 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-2530
Practice Address - Country:US
Practice Address - Phone:517-896-9346
Practice Address - Fax:517-589-5154
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901015968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist