Provider Demographics
NPI:1134214067
Name:MEDINA, JESUS JR (DDS)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:MEDINA
Suffix:JR
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 1:2911 N TENAYA WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0488
Mailing Address - Country:US
Mailing Address - Phone:702-368-3627
Mailing Address - Fax:702-368-3635
Practice Address - Street 1:2911 N TENAYA WAY STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0488
Practice Address - Country:US
Practice Address - Phone:702-368-3627
Practice Address - Fax:702-368-3635
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV 25121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice