Healthcare Provider Details

I. General information

NPI: 1457781320
Provider Name (Legal Business Name): BENJAMIN MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 MONTEREY HWY STE 30
SAN JOSE CA
95125-1069
US

IV. Provider business mailing address

320 SHADOW RUN DR
SAN JOSE CA
95110-3556
US

V. Phone/Fax

Practice location:
  • Phone: 408-295-1100
  • Fax:
Mailing address:
  • Phone: 408-896-3164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number26763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: