Provider Demographics
NPI:1821599630
Name:JUAN P MEDINA
Entity Type:Organization
Organization Name:JUAN P MEDINA
Other - Org Name:JUAN P MEDINA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-488-3200
Mailing Address - Street 1:AVE MADERO #S/N
Mailing Address - Street 2:
Mailing Address - City:LOS ALGODONES
Mailing Address - State:BAJA CALIFORNIA
Mailing Address - Zip Code:21970
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AVE MADERO #S/N
Practice Address - Street 2:
Practice Address - City:LOS ALGODONES
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:21970
Practice Address - Country:MX
Practice Address - Phone:619-488-3200
Practice Address - Fax:866-272-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
63251681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty