Provider Demographics
NPI:1033122775
Name:MEJIA, WANDA ESPERANZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:ESPERANZA
Last Name:MEJIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1966 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1231
Mailing Address - Country:US
Mailing Address - Phone:914-526-2144
Mailing Address - Fax:914-526-2187
Practice Address - Street 1:1966 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1231
Practice Address - Country:US
Practice Address - Phone:914-526-2144
Practice Address - Fax:914-526-2187
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048615122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02166109Medicaid