Provider Demographics
NPI:1619245685
Name:MEDINA, YESSENIA SOCORRO (RDA)
Entity Type:Individual
Prefix:MISS
First Name:YESSENIA
Middle Name:SOCORRO
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:MRS
Other - First Name:YESSENIA
Other - Middle Name:SOCORRO
Other - Last Name:NGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDA
Mailing Address - Street 1:104 N ROBIN PRIVADO
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4110
Mailing Address - Country:US
Mailing Address - Phone:909-455-3182
Mailing Address - Fax:
Practice Address - Street 1:104 N ROBIN PRIVADO
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764
Practice Address - Country:US
Practice Address - Phone:909-455-3182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67920126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant