Provider Demographics
NPI:1124256920
Name:MENDOZA, IRENIA (DDS)
Entity type:Individual
Prefix:DR
First Name:IRENIA
Middle Name:
Last Name:MENDOZA
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 1:8856 NW 110TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4557
Mailing Address - Country:US
Mailing Address - Phone:305-798-0559
Mailing Address - Fax:
Practice Address - Street 1:14138 SW 8TH ST
Practice Address - Street 2:#1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-3105
Practice Address - Country:US
Practice Address - Phone:786-717-7779
Practice Address - Fax:786-534-8863
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN185761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001290400Medicaid