Provider Demographics
NPI:1699121210
Name:MEJIA, GUADALUPE ANA
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:ANA
Last Name:MEJIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9108 32ND AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11369-2211
Mailing Address - Country:US
Mailing Address - Phone:347-430-2096
Mailing Address - Fax:
Practice Address - Street 1:12420 DAY ST STE B4
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7536
Practice Address - Country:US
Practice Address - Phone:951-656-6538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1001921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice