Provider Demographics
NPI:1598793432
Name:MEDINA-RIVERA, JUDITH MARIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:MARIA
Last Name:MEDINA-RIVERA
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 1:11521 N FM 620 STE 700
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1147
Mailing Address - Country:US
Mailing Address - Phone:512-560-0118
Mailing Address - Fax:512-986-5102
Practice Address - Street 1:11521 N FM 620 STE 700
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1147
Practice Address - Country:US
Practice Address - Phone:512-560-0118
Practice Address - Fax:512-986-5102
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2571122300000X
TX23136122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1970006-03Medicaid