Provider Demographics
NPI:1295815322
Name:VIVIAN MEDINA D.D.S P.A.
Entity type:Organization
Organization Name:VIVIAN MEDINA D.D.S P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-264-0286
Mailing Address - Street 1:15711 MAPLEDALE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-3112
Mailing Address - Country:US
Mailing Address - Phone:813-264-0286
Mailing Address - Fax:813-960-4667
Practice Address - Street 1:15711 MAPLEDALE DR
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-3112
Practice Address - Country:US
Practice Address - Phone:813-264-0286
Practice Address - Fax:813-960-4667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty