Provider Demographics
NPI:1366962334
Name:GUADALUPE A. MEJIA DENTAL CORP.
Entity type:Organization
Organization Name:GUADALUPE A. MEJIA DENTAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:ANA
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-553-0751
Mailing Address - Street 1:700 W 19TH ST.
Mailing Address - Street 2:SUITE C
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-722-9027
Mailing Address - Fax:
Practice Address - Street 1:700 W 19TH ST.
Practice Address - Street 2:SUITE C
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:949-722-9027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GUADALUPE A. MEJIA DENTAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1001921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty