Provider Demographics
NPI:1710990965
Name:MEDINA, IRWIN (DDS)
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SADORE LN APT 7X
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-4757
Mailing Address - Country:US
Mailing Address - Phone:914-393-5715
Mailing Address - Fax:
Practice Address - Street 1:47 E 77TH ST STE 216
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1730
Practice Address - Country:US
Practice Address - Phone:212-689-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051836122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051836OtherLICENSE