Provider Demographics
NPI:1144061904
Name:MEJIA, KIARA
Entity type:Individual
Prefix:
First Name:KIARA
Middle Name:
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 1:25 W RANDOLPH ST APT 2923
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-3526
Mailing Address - Country:US
Mailing Address - Phone:407-861-1918
Mailing Address - Fax:
Practice Address - Street 1:12231 E COLONIAL DR STE 150
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4761
Practice Address - Country:US
Practice Address - Phone:407-381-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN290191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice