Healthcare Provider Details

I. General information

NPI: 1538443577
Provider Name (Legal Business Name): KHARA MEJIA EFDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 NE 181ST AVE
PORTLAND OR
97230-6708
US

IV. Provider business mailing address

822 NE 181ST AVE
PORTLAND OR
97230-6708
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5210
  • Fax: 503-669-3989
Mailing address:
  • Phone: 503-661-5210
  • Fax: 503-669-3989

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: