MEDICARE: MIKENAH JOY VEGA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	341142	TX

General Provider Information

NPI Number	:	1912490822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKENAH JOY VEGA DMD

Provider Business Mailing Address
First Line	:	9303 HIGHWAY 6 STE 300
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-5156
Country	:	US
Telephone Number	:	832-539-3036
Fax Number	:

Provider Business Practice Location Address
First Line	:	9303 HIGHWAY 6 STE 300
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-5156
Country	:	US
Telephone Number	:	617-513-1360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2018
Last Update Date	:	02/08/2021

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