Healthcare Provider Details

I. General information

NPI: 1881379683
Provider Name (Legal Business Name): ANA MARIA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 TOLLAND STAGE RD
TOLLAND CT
06084-2924
US

IV. Provider business mailing address

9140 LAMONT AVE APT 2H
ELMHURST NY
11373-2762
US

V. Phone/Fax

Practice location:
  • Phone: 860-872-8551
  • Fax:
Mailing address:
  • Phone: 646-595-5582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13802
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: