Provider Demographics
NPI:1598152803
Name:MEDINA, DOMINIQUE J
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:J
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK ROAD
Mailing Address - Street 2:OHSU
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-494-8211
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:424-306-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1072471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery