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General NPI Number Information
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NPI Number | 1245645175
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Entity Type | Individual
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Provider Name | CARL MICHAEL MENTESANA DDS
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Gender | Male
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Dates
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Enumeration Date | 06/30/2014
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Last Update Date | 10/23/2020
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Provider Practice Location Address
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Address Line | 291 RENNER PKWY STE 103
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City | RICHARDSON
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State | TX
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Zip | 75080-1342
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Country | US
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Telephone | 214-738-6049
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Fax |
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Provider Business Mailing Address
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Address Line | 2403 LACY LN
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City | CARROLLTON
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State | TX
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Zip | 75006-6514
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Country | US
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Telephone | 972-869-3789
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30023
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 30023
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License Number State | TX
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