Provider Demographics
NPI:1548529951
Name:MENDOZA, ROSA ROMANO (DDS)
Entity type:Individual
Prefix:DR
First Name:ROSA
Middle Name:ROMANO
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROSA
Other - Middle Name:MARIA
Other - Last Name:ROMANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:6850 BROCKTON AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3814
Mailing Address - Country:US
Mailing Address - Phone:951-683-2006
Mailing Address - Fax:
Practice Address - Street 1:6850 BROCKTON AVE STE 106
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3814
Practice Address - Country:US
Practice Address - Phone:951-683-2006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000033656CAOtherDELTA DENTAL OF CALIFORNIA
CAB33656-01Medicaid