Provider Demographics
NPI:1932442332
Name:MEDINA, MARK R (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9955 CARMEL MOUNTAIN RD STE 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2815
Mailing Address - Country:US
Mailing Address - Phone:858-484-3100
Mailing Address - Fax:858-484-8510
Practice Address - Street 1:9955 CARMEL MOUNTAIN RD STE 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2815
Practice Address - Country:US
Practice Address - Phone:858-484-3100
Practice Address - Fax:858-484-8510
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist