MEDICARE: DR. MAURICIO MENDEZ SANDOVAL OD

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	390200000X	Student in an Organized Health Care Education/Training Program		NY

General Provider Information

NPI Number	:	1417817230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAURICIO MENDEZ SANDOVAL OD

Provider Business Mailing Address
First Line	:	1643 ROUTE 112 STE A
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763-3654
Country	:	US
Telephone Number	:	631-758-5575
Fax Number	:	631-758-5579

Provider Business Practice Location Address
First Line	:	1643 ROUTE 112 STE A
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763-3654
Country	:	US
Telephone Number	:	631-758-5575
Fax Number	:	631-758-5579

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

Provider Enumeration Date	:	11/13/2025
Last Update Date	:	11/13/2025

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