Provider Demographics
NPI:1366970048
Name:MENDOZA, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 SANDIFUR PKWY
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-9596
Mailing Address - Country:US
Mailing Address - Phone:509-302-2663
Mailing Address - Fax:509-302-2462
Practice Address - Street 1:8921 SANDIFUR PKWY STE 102
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9596
Practice Address - Country:US
Practice Address - Phone:509-302-2663
Practice Address - Fax:509-302-2462
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE607727661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE60772766OtherDEPT. OF HEALTH. WASHINGTON STATE