Jaques Gontijo Mezencio, DDS

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

41088 Issued in TX

Practice address

4901 E 42ND St Ste B
Odessa, TX 79762-7338

Phone

(432) 242-8827

NPI assigned

Nov 1, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1730419200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1730419200000",
    "number": "1568285237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8645 VIA TAVOLERIA WAY",
            "city": "WINDERMERE",
            "state": "FL",
            "postal_code": "347866828",
            "telephone_number": "561-843-4364"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4901 E 42ND ST STE B",
            "city": "ODESSA",
            "state": "TX",
            "postal_code": "797627338",
            "telephone_number": "432-242-8827"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GONTIJO MEZENCIO",
        "first_name": "JAQUES",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-11-01",
        "last_updated": "2024-11-01",
        "certification_date": "2024-11-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "TX",
            "license": "41088",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Orthodontics and Dentofacial Orthopedics Dentistry in Odessa, TX
• Providers in Odessa, TX by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.