Provider Demographics
NPI:1639576697
Name:MEDINA DENTAL PLLC
Entity Type:Organization
Organization Name:MEDINA DENTAL PLLC
Other - Org Name:LOCKPORT DENTAL GROUP PC D/B/S MEDINA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:STOCKTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-798-0100
Mailing Address - Street 1:610 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-1022
Mailing Address - Country:US
Mailing Address - Phone:585-798-0100
Mailing Address - Fax:585-798-3297
Practice Address - Street 1:610 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1022
Practice Address - Country:US
Practice Address - Phone:585-798-0100
Practice Address - Fax:585-798-3297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1497830483Medicaid