Healthcare Provider Details

I. General information

NPI: 1518589258
Provider Name (Legal Business Name): LUIS MENDIVIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2020
Last Update Date: 05/16/2020
Certification Date: 05/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AV MIGUEL HIDALGO 2313
SAN LUIS RIO COLORADO SONORA
83448
MX

IV. Provider business mailing address

4492 CAMINO DE LA PLZ # 607
SAN YSIDRO CA
92173-3071
US

V. Phone/Fax

Practice location:
  • Phone: 619-209-8924
  • Fax:
Mailing address:
  • Phone: 619-209-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LUIS MENDIVIL
Title or Position: DDS
Credential:
Phone: 619-209-8924