Provider Demographics
NPI:1508206657
Name:MEDINA, MARIA AHLEEN DE LEON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARIA AHLEEN
Middle Name:DE LEON
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7698 SAN SIMEON DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-5736
Mailing Address - Country:US
Mailing Address - Phone:916-276-6942
Mailing Address - Fax:
Practice Address - Street 1:1350 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5208
Practice Address - Country:US
Practice Address - Phone:530-477-8545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist