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General NPI Number Information
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NPI Number | 1568285237
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Entity Type | Individual
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Provider Name | JAQUES GONTIJO MEZENCIO DDS
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Gender | Male
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Dates
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Enumeration Date | 11/01/2024
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 4901 E 42ND ST STE B
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City | ODESSA
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State | TX
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Zip | 79762-7338
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Country | US
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Telephone | 432-242-8827
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Fax |
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Provider Business Mailing Address
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Address Line | 8645 VIA TAVOLERIA WAY
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City | WINDERMERE
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State | FL
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Zip | 34786-6828
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Country | US
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Telephone | 561-843-4364
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 41088
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License Number State | TX
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