Provider Demographics
NPI:1376620344
Name:MESA, GEORGINA (DMD)
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:MESA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13550 SW 120TH ST
Mailing Address - Street 2:STE 512
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7507
Mailing Address - Country:US
Mailing Address - Phone:305-380-7000
Mailing Address - Fax:786-227-5315
Practice Address - Street 1:1878 SW 57 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-262-9299
Practice Address - Fax:305-262-8772
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00134281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36710OtherBLUE CROSS BLUE SHIELD
FL075011500Medicaid
FL979361OtherUNITED CONCORDIA