MEDICARE: DR. JORGE MENDIETA D.D.S.

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	1223G0001X	General Practice Dentistry	043265-1	NY

General Provider Information

NPI Number	:	1619967379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE MENDIETA D.D.S.

Provider Business Mailing Address
First Line	:	2000 BROADWAY
Second Line	:	#16-G
City	:	NEW YORK
State	:	NY
Zip	:	10023-5028
Country	:	US
Telephone Number	:	212-496-5090
Fax Number	:

Provider Business Practice Location Address
First Line	:	CAS/MILBANK MEDICAL GROUP
Second Line	:	14-32 WEST 118 STREET
City	:	NEW YORK
State	:	NY
Zip	:	10026-1904
Country	:	US
Telephone Number	:	212-369-8339
Fax Number	:

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

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. JORGE MENDIETA D.D.S.” Practice Location

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