Healthcare Provider Details

I. General information

NPI: 1902967904
Provider Name (Legal Business Name): JULITA MENDOZA LUCIO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14550 HAYNES ST
VAN NUYS CA
91411-1613
US

IV. Provider business mailing address

14550 HAYNES ST
VAN NUYS CA
91411-1613
US

V. Phone/Fax

Practice location:
  • Phone: 818-650-6700
  • Fax:
Mailing address:
  • Phone: 818-650-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number47938
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: