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General NPI Number Information
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NPI Number | 1851686562
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Entity Type | Organization
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Legal Business Name | MENDIETA, LLC
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Dates
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Enumeration Date | 06/10/2011
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Last Update Date | 06/10/2011
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Provider Practice Location Address
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Address Line | 3079 W BROAD ST STE 6
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City | COLUMBUS
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State | OH
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Zip | 43204-1397
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Country | US
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Telephone | 614-279-6481
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Fax |
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Provider Business Mailing Address
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Address Line | 3079 W BROAD ST STE 6
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City | COLUMBUS
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State | OH
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Zip | 43204-1397
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Country | US
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Telephone | 614-279-6481
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. EDGAR YAHIR MENDIETA
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Credential | DDS
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Telephone | 310-592-2057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 30.022430
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License Number State | OH
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