Provider Demographics
NPI:1447072400
Name:MENDOZA, DAVID ANDRES
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDRES
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82151 AVENUE 42 STE 110
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-9313
Mailing Address - Country:US
Mailing Address - Phone:760-255-7597
Mailing Address - Fax:
Practice Address - Street 1:82151 AVENUE 42 STE 110
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92203-9313
Practice Address - Country:US
Practice Address - Phone:760-255-7597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS109877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist