Healthcare Provider Details

I. General information

NPI: 1285992289
Provider Name (Legal Business Name): MEJIA & PENALOZA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 N PLEASANTBURG DR STE D
GREENVILLE SC
29607-1256
US

IV. Provider business mailing address

1140 N PLEASANTBURG DR STE D
GREENVILLE SC
29607-1256
US

V. Phone/Fax

Practice location:
  • Phone: 864-252-8296
  • Fax:
Mailing address:
  • Phone: 864-252-8296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6992
License Number State

VIII. Authorized Official

Name: PAOLA MEJIA
Title or Position: MANAGER
Credential:
Phone: 864-252-8296