MEDICARE: MS. JAQUELINE MENDOZA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	126800000X	Dental Assistant	35054	TX

General Provider Information

NPI Number	:	1275089807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAQUELINE MENDOZA

Provider Business Mailing Address
First Line	:	336 RALPH ST
Second Line	:
City	:	CHAPARRAL
State	:	NM
Zip	:	88081-7559
Country	:	US
Telephone Number	:	915-301-4590
Fax Number	:

Provider Business Practice Location Address
First Line	:	11334 SSG SIMS
Second Line	:
City	:	FT. BLISS
State	:	TX
Zip	:	79908
Country	:	US
Telephone Number	:	915-301-4590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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