Provider Demographics
NPI:1548831258
Name:MEJIA, SEBASTIAN
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:MEJIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 BROOKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-4713
Mailing Address - Country:US
Mailing Address - Phone:972-836-2974
Mailing Address - Fax:
Practice Address - Street 1:2771 E BROAD ST STE 221
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9157
Practice Address - Country:US
Practice Address - Phone:817-473-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-03
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX373381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice