Provider Demographics
NPI:1003065988
Name:MEDINNUS, MARK GRANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GRANT
Last Name:MEDINNUS
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:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:MAD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95552-4302
Mailing Address - Country:US
Mailing Address - Phone:530-467-3517
Mailing Address - Fax:
Practice Address - Street 1:9024 SNIKTAW LN
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9408
Practice Address - Country:US
Practice Address - Phone:530-468-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice