Provider Demographics
NPI:1215597695
Name:MEDINA, ANDRE ALBERTO
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:ALBERTO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9365 SW 77TH AVE APT 1003
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7938
Mailing Address - Country:US
Mailing Address - Phone:786-271-4672
Mailing Address - Fax:
Practice Address - Street 1:2501 SW 22ND ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3403
Practice Address - Country:US
Practice Address - Phone:305-858-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24247122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist