Healthcare Provider Details

I. General information

NPI: 1295258614
Provider Name (Legal Business Name): JORGE DANIEL MEJIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MANCHESTER AVE
DERRY NH
03038-1931
US

IV. Provider business mailing address

379 OAK ST
MANCHESTER NH
03104-2616
US

V. Phone/Fax

Practice location:
  • Phone: 603-434-1586
  • Fax:
Mailing address:
  • Phone: 703-953-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1857612
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: