Provider Demographics
NPI:1417062472
Name:MARK R MEDINA & THOMAS KERRIAN
Entity Type:Organization
Organization Name:MARK R MEDINA & THOMAS KERRIAN
Other - Org Name:RANCHO PENASQUITOS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:KERRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:858-484-3100
Mailing Address - Street 1:9955 CARMEL MOUNTAIN RD STE 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2815
Mailing Address - Country:US
Mailing Address - Phone:858-484-3100
Mailing Address - Fax:858-484-8510
Practice Address - Street 1:9955 CARMEL MOUNTAIN RD STE 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2815
Practice Address - Country:US
Practice Address - Phone:858-484-3100
Practice Address - Fax:858-484-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA311291223G0001X
CA255951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25595OtherSTATE ID
CA31129OtherSTATE ID