=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912054271
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUY WILLIAM MENDIVIL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 01/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11901 BOLTHOUSE DR STE 200
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311-8456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-323-5910
-----------------------------------------------------
Fax | 661-323-5911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11901 BOLTHOUSE DR STE 200
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93311-8456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-323-5910
-----------------------------------------------------
Fax | 661-323-5911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D29737
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------