Provider Demographics
NPI:1336523679
Name:MEDRANO, VANINA HAYDEE (DMD)
Entity Type:Individual
Prefix:
First Name:VANINA
Middle Name:HAYDEE
Last Name:MEDRANO
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 1:1600 MALL OF GEORGIA BLVD
Mailing Address - Street 2:SUITE 1230
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8749
Mailing Address - Country:US
Mailing Address - Phone:678-606-0166
Mailing Address - Fax:678-606-0167
Practice Address - Street 1:1600 MALL OF GEORGIA BLVD
Practice Address - Street 2:SUITE 1230
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8749
Practice Address - Country:US
Practice Address - Phone:678-606-0166
Practice Address - Fax:678-606-0166
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist