Healthcare Provider Details

I. General information

NPI: 1548831258
Provider Name (Legal Business Name): SEBASTIAN MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2771 E BROAD ST STE 221
MANSFIELD TX
76063-9157
US

IV. Provider business mailing address

3212 BROOKSHIRE DR
PLANO TX
75075-4713
US

V. Phone/Fax

Practice location:
  • Phone: 817-473-2277
  • Fax:
Mailing address:
  • Phone: 972-836-2974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37338
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: