Provider Demographics
NPI:1003827551
Name:MEDINA, DIANA MARCELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:MARCELA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 EASTBORNE AVE
Mailing Address - Street 2:APT # 302
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5985
Mailing Address - Country:US
Mailing Address - Phone:310-490-6674
Mailing Address - Fax:
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 505
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5012
Practice Address - Country:US
Practice Address - Phone:310-820-6691
Practice Address - Fax:310-820-6041
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA506431223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery