Provider Demographics
NPI:1558446575
Name:MEDINA, MYRNA JOSE (DDS)
Entity type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:JOSE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PENNY LN STE 1
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6010
Mailing Address - Country:US
Mailing Address - Phone:831-722-4635
Mailing Address - Fax:831-722-5735
Practice Address - Street 1:15 PENNY LN STE 1
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6010
Practice Address - Country:US
Practice Address - Phone:831-722-4635
Practice Address - Fax:831-722-5735
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist