Healthcare Provider Details

I. General information

NPI: 1770625253
Provider Name (Legal Business Name): EVA SUZANNE MEJIA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 1/2 EDISON AVE.
ALAMOSA CO
81101
US

IV. Provider business mailing address

100 1/2 EDISON AVE.
ALAMOSA CO
81101
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-4953
  • Fax: 719-587-9946
Mailing address:
  • Phone: 719-589-4953
  • Fax: 719-587-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6005 015
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9838
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: