Provider Demographics
NPI:1760667091
Name:MENDOTA DENTAL ASSOCIATES
Entity type:Organization
Organization Name:MENDOTA DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-226-1784
Mailing Address - Street 1:720 MAIN ST
Mailing Address - Street 2:SUITE 213
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3757
Mailing Address - Country:US
Mailing Address - Phone:651-454-1502
Mailing Address - Fax:651-454-1504
Practice Address - Street 1:720 MAIN ST
Practice Address - Street 2:SUITE 213
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118-3757
Practice Address - Country:US
Practice Address - Phone:651-454-1502
Practice Address - Fax:651-454-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-06
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty