Healthcare Provider Details

I. General information

NPI: 1720610413
Provider Name (Legal Business Name): ELSA JOHANA MEJIA DENTAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 SHARLANDS AVE STE 3
RENO NV
89523-3729
US

IV. Provider business mailing address

6255 SHARLANDS AVE STE 3
RENO NV
89523-3729
US

V. Phone/Fax

Practice location:
  • Phone: 775-339-3015
  • Fax: 702-947-4803
Mailing address:
  • Phone: 775-339-3015
  • Fax: 702-947-4803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: