Healthcare Provider Details

I. General information

NPI: 1225910805
Provider Name (Legal Business Name): INTI MENDOZA CARRASCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 BROAD ST
SUMTER SC
29150-1973
US

IV. Provider business mailing address

8210 FOUNTAIN AVE # 203
WEST HOLLYWOOD CA
90046-3713
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-1355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11225
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: