Provider Demographics
NPI:1902073307
Name:GUY W MENDIVIL, D.D.S. PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:GUY W MENDIVIL, D.D.S. PROFESSIONAL DENTAL CORPORATION
Other - Org Name:TRI-CITY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MENDIVIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-945-4692
Mailing Address - Street 1:3998 VISTA WAY SUITE B
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056
Mailing Address - Country:US
Mailing Address - Phone:760-945-1420
Mailing Address - Fax:760-945-4692
Practice Address - Street 1:3998 VISTA WAY SUITE B
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056
Practice Address - Country:US
Practice Address - Phone:760-945-1420
Practice Address - Fax:760-945-4692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD297371223X0400X
CA1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93914-02OtherMEDI-CAL/DENTI-CAL
CAG9391402OtherDENTI-CAL PROVIDER