Provider Demographics
NPI:1689831406
Name:MEJIA, OCTAVIO JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:
Last Name:MEJIA
Suffix:JR
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 1:2103 E GRIFFIN PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-3490
Mailing Address - Country:US
Mailing Address - Phone:956-583-9880
Mailing Address - Fax:956-583-1383
Practice Address - Street 1:2103 E GRIFFIN PKWY STE A
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-3490
Practice Address - Country:US
Practice Address - Phone:956-583-9880
Practice Address - Fax:956-583-1383
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19615122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142541505Medicaid
TXB19615OtherDELTAL DENTAL STATE GOVERMENT PROGRAMS