Healthcare Provider Details

I. General information

NPI: 1558819615
Provider Name (Legal Business Name): EDUARDO A MEJIA DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2257 N LOOP 336 W STE 120
CONROE TX
77304-3566
US

IV. Provider business mailing address

2257 N LOOP 336 W STE 120
CONROE TX
77304-3566
US

V. Phone/Fax

Practice location:
  • Phone: 936-588-9303
  • Fax: 936-756-9393
Mailing address:
  • Phone: 936-588-9303
  • Fax: 936-756-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22766
License Number StateTX

VIII. Authorized Official

Name: DR. EDUARDO A. MEJIA
Title or Position: OWNER
Credential:
Phone: 936-588-9303