Provider Demographics
NPI:1265014310
Name:MEDINA SUAREZ, TAILYN (DMD)
Entity Type:Individual
Prefix:
First Name:TAILYN
Middle Name:
Last Name:MEDINA SUAREZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CALLE GALILEO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927-4703
Mailing Address - Country:US
Mailing Address - Phone:512-662-6063
Mailing Address - Fax:
Practice Address - Street 1:5304 STATION PL
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2351
Practice Address - Country:US
Practice Address - Phone:512-662-6063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0438931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program