Provider Demographics
NPI:1225100464
Name:EADES, MEDINA ROBERTS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEDINA
Middle Name:ROBERTS
Last Name:EADES
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 1:2092 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-5424
Mailing Address - Country:US
Mailing Address - Phone:760-598-6431
Mailing Address - Fax:760-749-8828
Practice Address - Street 1:27545 VALLEY CENTER RD
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-6538
Practice Address - Country:US
Practice Address - Phone:760-749-8824
Practice Address - Fax:760-749-8828
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice