Provider Demographics
NPI:1851995229
Name:MEDINA, GRACIELA REBECA II
Entity Type:Individual
Prefix:MISS
First Name:GRACIELA
Middle Name:REBECA
Last Name:MEDINA
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7352 MEADE CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5439
Mailing Address - Country:US
Mailing Address - Phone:909-435-1376
Mailing Address - Fax:
Practice Address - Street 1:7352 MEADE CT
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5439
Practice Address - Country:US
Practice Address - Phone:909-613-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88142126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant