Provider Demographics
NPI:1568285237
Name:GONTIJO MEZENCIO, JAQUES (DDS)
Entity type:Individual
Prefix:DR
First Name:JAQUES
Middle Name:
Last Name:GONTIJO MEZENCIO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8645 VIA TAVOLERIA WAY
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6828
Mailing Address - Country:US
Mailing Address - Phone:561-843-4364
Mailing Address - Fax:
Practice Address - Street 1:4901 E 42ND ST STE B
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7338
Practice Address - Country:US
Practice Address - Phone:432-242-8827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX410881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty