Provider Demographics
NPI:1336211309
Name:MEDINA, MARILOU PANGANIBAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARILOU
Middle Name:PANGANIBAN
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14451 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3069
Mailing Address - Country:US
Mailing Address - Phone:909-355-6400
Mailing Address - Fax:
Practice Address - Street 1:14451 FOOTHILL BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3069
Practice Address - Country:US
Practice Address - Phone:909-355-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice