Provider Demographics
NPI:1457451536
Name:J.M. MEDINA, D.M.D., P.A.
Entity Type:Organization
Organization Name:J.M. MEDINA, D.M.D., P.A.
Other - Org Name:MEDINA ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:210-695-1738
Mailing Address - Street 1:11868 BANDERA RD
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4132
Mailing Address - Country:US
Mailing Address - Phone:210-695-1738
Mailing Address - Fax:210-695-1736
Practice Address - Street 1:11868 BANDERA RD
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4132
Practice Address - Country:US
Practice Address - Phone:210-695-1738
Practice Address - Fax:210-695-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20136261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental