Provider Demographics
NPI:1275000887
Name:MEDINA, ERICA DIANE (RDH)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:DIANE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 310001-0670
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0670
Mailing Address - Country:US
Mailing Address - Phone:575-758-6966
Mailing Address - Fax:575-751-5211
Practice Address - Street 1:1090 GOAT SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-6966
Practice Address - Fax:575-751-5211
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH4180124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK3543Medicaid