Basic Information
| Provider Information | |||||||||
| NPI: | 1528119112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDEZ | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616640145 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1311 GENERAL CAVAZOS BLVD STE 303C | ||||||||
| Address2: | |||||||||
| City: | KINGSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615923237 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 16588 | TX | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 009033404 | 05 | TX | MEDICAID | 009033401 | 05 | TX | MEDICAID | 171353901 | 05 | TX | MEDICAID |