Provider Demographics
NPI:1073630760
Name:MEDINA, JOSE A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 CALLE AMARILLO
Mailing Address - Street 2:SUITE 207-B (BOX 16)
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-3072
Mailing Address - Country:US
Mailing Address - Phone:787-765-7248
Mailing Address - Fax:787-765-3416
Practice Address - Street 1:1738 CALLE AMARILLO
Practice Address - Street 2:SUITE 207-B (BOX 16)
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-3072
Practice Address - Country:US
Practice Address - Phone:787-765-7248
Practice Address - Fax:787-765-3416
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR20081223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics