Healthcare Provider Details

I. General information

NPI: 1295410801
Provider Name (Legal Business Name): EMILY LISSETH MEJIA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 W SLAUGHTER LN STE 190
AUSTIN TX
78748-5997
US

IV. Provider business mailing address

13112 POLLARD DR
AUSTIN TX
78727-7023
US

V. Phone/Fax

Practice location:
  • Phone: 512-593-4465
  • Fax:
Mailing address:
  • Phone: 512-316-6136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number39574
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: