Provider Demographics
NPI:1609393438
Name:DERENTZ, MONA (DDS)
Entity type:Individual
Prefix:DR
First Name:MONA
Middle Name:
Last Name:DERENTZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 AUTUMN LEAF DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-2607
Mailing Address - Country:US
Mailing Address - Phone:805-630-4541
Mailing Address - Fax:
Practice Address - Street 1:31370 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4356
Practice Address - Country:US
Practice Address - Phone:805-630-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1000111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics