Provider Demographics
NPI:1417088113
Name:OLIVERIA, RESURRECCION MEDINA (DDS)
Entity Type:Individual
Prefix:
First Name:RESURRECCION
Middle Name:MEDINA
Last Name:OLIVERIA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RED GRANITE RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2854
Mailing Address - Country:US
Mailing Address - Phone:619-656-9970
Mailing Address - Fax:
Practice Address - Street 1:1072A 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2009
Practice Address - Country:US
Practice Address - Phone:619-425-5323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49622Medicaid