Healthcare Provider Details

I. General information

NPI: 1689831406
Provider Name (Legal Business Name): OCTAVIO MEJIA JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 E GRIFFIN PKWY STE A
MISSION TX
78572-3490
US

IV. Provider business mailing address

2103 E GRIFFIN PKWY STE A
MISSION TX
78572-3490
US

V. Phone/Fax

Practice location:
  • Phone: 956-583-9880
  • Fax: 956-583-1383
Mailing address:
  • Phone: 956-583-9880
  • Fax: 956-583-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number19615
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19615
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: