Provider Demographics
NPI:1699419481
Name:MENA, RODA JEAN (DDS)
Entity type:Individual
Prefix:
First Name:RODA
Middle Name:JEAN
Last Name:MENA
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 1:555 W KINZIE ST APT 2512
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5856
Mailing Address - Country:US
Mailing Address - Phone:651-734-5107
Mailing Address - Fax:
Practice Address - Street 1:5225 TOUHY AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3245
Practice Address - Country:US
Practice Address - Phone:847-807-7341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.033763122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program