Provider Demographics
NPI:1477167419
Name:MEDINA, JAQUELINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAQUELINE
Middle Name:
Last Name:MEDINA
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 1:4700 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75223-2131
Mailing Address - Country:US
Mailing Address - Phone:469-571-1942
Mailing Address - Fax:
Practice Address - Street 1:2780 FM 365
Practice Address - Street 2:SUITE C
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640
Practice Address - Country:US
Practice Address - Phone:409-332-4701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX365991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice