Healthcare Provider Details

I. General information

NPI: 1306204045
Provider Name (Legal Business Name): MRS. TERESA MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19075 NW TANASBOURNE DR STE 300
HILLSBORO OR
97124-5802
US

IV. Provider business mailing address

19075 NW TANASBOURNE DR STE 300
HILLSBORO OR
97124-5802
US

V. Phone/Fax

Practice location:
  • Phone: 503-531-1700
  • Fax: 503-531-1704
Mailing address:
  • Phone: 503-531-1700
  • Fax: 503-531-1704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberA9650
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: