Provider Demographics
NPI:1245803741
Name:MEDINA, DIANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
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 1:195 W DAVIS ST APT 303
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4423
Mailing Address - Country:US
Mailing Address - Phone:903-434-9781
Mailing Address - Fax:
Practice Address - Street 1:5330 E MOCKINGBIRD LN STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-0941
Practice Address - Country:US
Practice Address - Phone:214-821-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX375281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice