Healthcare Provider Details

I. General information

NPI: 1194455352
Provider Name (Legal Business Name): FABIAN A MENDOZA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 06/12/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 CENTRAL AVE NE
ALBUQUERQUE NM
87108-1601
US

IV. Provider business mailing address

15402 OAKLAWN PARK DR
HOUSTON TX
77069-1512
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-6060
  • Fax:
Mailing address:
  • Phone: 832-982-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5630
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: