Healthcare Provider Details

I. General information

NPI: 1144061904
Provider Name (Legal Business Name): KIARA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12231 E COLONIAL DR STE 150
ORLANDO FL
32826-4761
US

IV. Provider business mailing address

25 W RANDOLPH ST APT 2923
CHICAGO IL
60601-3526
US

V. Phone/Fax

Practice location:
  • Phone: 407-381-1960
  • Fax:
Mailing address:
  • Phone: 407-861-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN29019
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: