Provider Demographics
NPI:1285992289
Name:MEJIA & PENALOZA LLC
Entity type:Organization
Organization Name:MEJIA & PENALOZA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-252-8296
Mailing Address - Street 1:1140 N PLEASANTBURG DR STE D
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-1256
Mailing Address - Country:US
Mailing Address - Phone:864-252-8296
Mailing Address - Fax:
Practice Address - Street 1:1140 N PLEASANTBURG DR STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-1256
Practice Address - Country:US
Practice Address - Phone:864-252-8296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
69921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty