Provider Demographics
NPI:1669642963
Name:MARILOU P. MEDINA, DMD, INC.
Entity Type:Organization
Organization Name:MARILOU P. MEDINA, DMD, INC.
Other - Org Name:MARYKNOLL DENTAL OFFICE OF MARILOU P. MEDINA, DMD, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILOU
Authorized Official - Middle Name:PANGANIBAN
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:909-355-6400
Mailing Address - Street 1:14451 FOOTHILL BLVD.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335
Mailing Address - Country:US
Mailing Address - Phone:909-355-6400
Mailing Address - Fax:909-355-6411
Practice Address - Street 1:14451 FOOTHILL BLVD.
Practice Address - Street 2:SUITE 104
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:909-355-6400
Practice Address - Fax:909-355-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty