MEDICARE: MISS MARISELA B MENDOZA R.D.H, B.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	124Q00000X	Dental Hygienist	21806	CA

General Provider Information

NPI Number	:	1992926216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARISELA B MENDOZA R.D.H, B.S

Provider Business Mailing Address
First Line	:	32 LEMON BLOSSOM CT
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123
Country	:	US
Telephone Number	:	408-394-7155
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 LEMON BLOSSOM CT
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95123-2127
Country	:	US
Telephone Number	:	408-394-7155
Fax Number	:

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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