Provider Demographics
NPI:1720412042
Name:MEDINA, ADRIAN (DDS)
Entity Type:Individual
Prefix:
First Name:ADRIAN
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 1:10 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-3332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3121
Practice Address - Country:US
Practice Address - Phone:410-383-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16177122300000X
NY057653122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist