Provider Demographics
NPI:1265127922
Name:MEDINA, JOHANA L
Entity type:Individual
Prefix:
First Name:JOHANA
Middle Name:L
Last Name:MEDINA
Suffix:
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 1:345 COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:RIFLE
Mailing Address - State:CO
Mailing Address - Zip Code:81650-9353
Mailing Address - Country:US
Mailing Address - Phone:970-274-1146
Mailing Address - Fax:
Practice Address - Street 1:0405 CASTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611
Practice Address - Country:US
Practice Address - Phone:970-929-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002024469124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist