Basic Information
| Provider Information | |||||||||
| NPI: | 1225194640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONDESIR | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | OLIVIA | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199559470 | ||||||||
| Practice Location | |||||||||
| Address1: | 5632 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104850008 | ||||||||
| FaxNumber: | 4104350444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12218 | MD | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1225194640 | 05 | MD | MEDICAID |