Healthcare Provider Details

I. General information

NPI: 1033122775
Provider Name (Legal Business Name): WANDA ESPERANZA MEJIA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/10/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 E. MAIN ST MOHEGAN LAKE NY 10547
MOHEGAN LAKE NY
10547
US

IV. Provider business mailing address

5295 ARLINGTON AVE
BX NY
10471
US

V. Phone/Fax

Practice location:
  • Phone: 914-526-2144
  • Fax: 914-526-2187
Mailing address:
  • Phone: 646-330-9412
  • Fax: 914-526-2187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number048615
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: