Provider Demographics
NPI:1629564240
Name:MEDINA, BENANETTE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENANETTE
Middle Name:
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:PO BOX 1810
Mailing Address - Street 2:PMB 753
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680
Mailing Address - Country:US
Mailing Address - Phone:787-234-3520
Mailing Address - Fax:
Practice Address - Street 1:PINEIRO AVE
Practice Address - Street 2:PLAZA EL AMAL OFICINA 211
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-0092
Practice Address - Country:US
Practice Address - Phone:787-765-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR0033291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program