Provider Demographics
NPI:1174694806
Name:MONDEJAR, AGNES S (DDS)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:S
Last Name:MONDEJAR
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821
Mailing Address - Country:US
Mailing Address - Phone:562-691-3788
Mailing Address - Fax:562-691-3307
Practice Address - Street 1:1245 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821
Practice Address - Country:US
Practice Address - Phone:562-691-3788
Practice Address - Fax:562-691-3307
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice