Provider Demographics
NPI:1477950731
Name:MEDLENOV, MARIYA (DDS)
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:MEDLENOV
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 1:42 CHATSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-4187
Mailing Address - Country:US
Mailing Address - Phone:267-288-3355
Mailing Address - Fax:
Practice Address - Street 1:241 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PINE BEACH
Practice Address - State:NJ
Practice Address - Zip Code:08741-1544
Practice Address - Country:US
Practice Address - Phone:732-341-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025792001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice