Provider Demographics
NPI:1952709230
Name:AGNES S. MONDEJAR, D.D.S., INC.
Entity Type:Organization
Organization Name:AGNES S. MONDEJAR, D.D.S., INC.
Other - Org Name:BREA CHILDREN'S DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:S
Authorized Official - Last Name:MONDEJAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-536-6107
Mailing Address - Street 1:1245 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-2407
Mailing Address - Country:US
Mailing Address - Phone:562-691-3788
Mailing Address - Fax:562-697-4686
Practice Address - Street 1:1245 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-2407
Practice Address - Country:US
Practice Address - Phone:562-691-3788
Practice Address - Fax:562-697-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93555-01OtherDENTI-CAL