1902073307 NPI number — GUY W MENDIVIL, D.D.S. PROFESSIONAL DENTAL CORPORATION

Table of content: (NPI 1902073307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902073307 NPI number — GUY W MENDIVIL, D.D.S. PROFESSIONAL DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUY W MENDIVIL, D.D.S. PROFESSIONAL DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TRI-CITY ORTHODONTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902073307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3998 VISTA WAY SUITE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEANSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-945-1420
Provider Business Mailing Address Fax Number:
760-945-4692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3998 VISTA WAY SUITE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-945-1420
Provider Business Practice Location Address Fax Number:
760-945-4692
Provider Enumeration Date:
05/14/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MENDIVIL
Authorized Official First Name:
GUY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-945-4692

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  D29737 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G93914-02 . This is a "MEDI-CAL/DENTI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G9391402 . This is a "DENTI-CAL PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".