Provider Demographics
NPI:1538274998
Name:MEJIA MOLINA, JOSE MARIO (DDS)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MARIO
Last Name:MEJIA MOLINA
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 1:131 SKY LINE RANCH DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-8739
Mailing Address - Country:US
Mailing Address - Phone:707-301-0491
Mailing Address - Fax:
Practice Address - Street 1:3400 SONOMA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590
Practice Address - Country:US
Practice Address - Phone:707-554-4000
Practice Address - Fax:707-554-6146
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49598122300000X
FLDH16272124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49598Medicare ID - Type UnspecifiedDENTI-CAL