Provider Demographics
NPI:1417445420
Name:MEDINA MATOS, MELISSA MARIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIA
Last Name:MEDINA MATOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY GARDENS AUSUBO ST. J-23
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-233-3508
Mailing Address - Fax:
Practice Address - Street 1:CARR. 628 KM 3.9
Practice Address - Street 2:BO. MANANTIALES, SECTOR JOBALES
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-881-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR32941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program