Provider Demographics
NPI:1639905029
Name:RENDON MEDINA, MAYRA ALEXANDRA (DDS, MSC)
Entity type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:ALEXANDRA
Last Name:RENDON MEDINA
Suffix:
Gender:F
Credentials:DDS, MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 MARLBOROUGH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-1504
Mailing Address - Country:US
Mailing Address - Phone:617-212-3266
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5888
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:617-432-4258
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADNL100150122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist