Provider Demographics
NPI:1326226440
Name:MEDELLIN, JOE (DDS)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:MEDELLIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8949 RESEDA BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-3995
Mailing Address - Country:US
Mailing Address - Phone:818-280-5596
Mailing Address - Fax:818-975-5596
Practice Address - Street 1:8949 RESEDA BLVD STE 116
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-280-5596
Practice Address - Fax:818-975-5596
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56535122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist