Provider Demographics
NPI:1578854303
Name:MEZA, LUIS MANUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MANUEL
Last Name:MEZA
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 1:3115 MIDDLEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3731
Mailing Address - Country:US
Mailing Address - Phone:650-365-7217
Mailing Address - Fax:650-365-7023
Practice Address - Street 1:3115 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3731
Practice Address - Country:US
Practice Address - Phone:650-365-7217
Practice Address - Fax:650-365-7023
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24639122300000X, 1223E0200X, 1223G0001X, 1223P0221X, 1223P0700X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223E0200XDental ProvidersDentistEndodontics
No1223P0221XDental ProvidersDentistPediatric Dentistry
No1223P0700XDental ProvidersDentistProsthodontics
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics