Provider Demographics
NPI:1306388244
Name:MEDINA, SUSAN (RDH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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:PO BOX 120
Mailing Address - Street 2:1062 STATE RT 38
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1062 STATE RT 38
Practice Address - Street 2:SUITE 120
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827
Practice Address - Country:US
Practice Address - Phone:607-687-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022904124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist