Healthcare Provider Details

I. General information

NPI: 1407903032
Provider Name (Legal Business Name): MARK ANTHONY MANUEL MENDIOLA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S CALIFORNIA AVE
CHICAGO IL
60608-2486
US

IV. Provider business mailing address

345 N LA SALLE DR UNIT 4407
CHICAGO IL
60610-6101
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-1201
  • Fax:
Mailing address:
  • Phone: 248-210-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: