Provider Demographics
NPI:1134738156
Name:MEDINA, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 E GRAND AVE APT 1304
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-4163
Mailing Address - Country:US
Mailing Address - Phone:903-799-0553
Mailing Address - Fax:
Practice Address - Street 1:7510 E GRAND AVE APT 1304
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-4163
Practice Address - Country:US
Practice Address - Phone:903-799-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-26
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty