Healthcare Provider Details

I. General information

NPI: 1225604754
Provider Name (Legal Business Name): RANDY MEJIAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 S AVALON PARK BLVD
ORLANDO FL
32828-6781
US

IV. Provider business mailing address

8206 WOODMONT CIR
MACUNGIE PA
18062-8684
US

V. Phone/Fax

Practice location:
  • Phone: 321-710-3435
  • Fax:
Mailing address:
  • Phone: 786-444-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN25396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: