Healthcare Provider Details

I. General information

NPI: 1952875635
Provider Name (Legal Business Name): LUIS CARLOS MEJIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MALABAR RD SE STE 3
PALM BAY FL
32907-3109
US

IV. Provider business mailing address

620 MALABAR RD SE STE 3
PALM BAY FL
32907-3109
US

V. Phone/Fax

Practice location:
  • Phone: 786-622-3950
  • Fax:
Mailing address:
  • Phone: 786-622-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number23915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: