Healthcare Provider Details

I. General information

NPI: 1649490509
Provider Name (Legal Business Name): EDUARDO A MEJIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 936-756-4966
  • Fax: 936-756-4966
Mailing address:
  • Phone: 936-756-4966
  • Fax: 936-756-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22766
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: