Provider Demographics
NPI:1164982971
Name:MEDINA CARABALLO, SOFIA
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:MEDINA CARABALLO
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 1:1738 CALLE AMARILLO SUMMIT BUILDING
Mailing Address - Street 2:BOX 16
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-472-4567
Mailing Address - Fax:
Practice Address - Street 1:1738 CALLE AMARILLO SUMMIT BUILDING
Practice Address - Street 2:207B
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:718-630-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR34461223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics