Provider Demographics
NPI:1922764927
Name:MEDINA, MARISSA (DDS)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 WICHITA ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-5745
Mailing Address - Country:US
Mailing Address - Phone:832-428-2200
Mailing Address - Fax:
Practice Address - Street 1:10128 HAMMERLY BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77080-5010
Practice Address - Country:US
Practice Address - Phone:832-428-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist