Healthcare Provider Details

I. General information

NPI: 1144965633
Provider Name (Legal Business Name): NICOLAS MEJIO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15795 SW 152ND ST
MIAMI FL
33187-5417
US

IV. Provider business mailing address

7611 SW 78TH CT
MIAMI FL
33143-4029
US

V. Phone/Fax

Practice location:
  • Phone: 305-547-8390
  • Fax:
Mailing address:
  • Phone: 813-454-8961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27823
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: