Provider Demographics
NPI:1881296994
Name:THIBEDEAUX-HARRIS, MEKKA
Entity type:Individual
Prefix:
First Name:MEKKA
Middle Name:
Last Name:THIBEDEAUX-HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1458
Mailing Address - Country:US
Mailing Address - Phone:323-652-7064
Mailing Address - Fax:
Practice Address - Street 1:11635 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:CA
Practice Address - Zip Code:90701-6628
Practice Address - Country:US
Practice Address - Phone:310-409-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90532126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant