Provider Demographics
NPI:1932576824
Name:MEDINA, ALFRED A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:A
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 1:309 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-3910
Mailing Address - Country:US
Mailing Address - Phone:619-420-6030
Mailing Address - Fax:619-420-9102
Practice Address - Street 1:309 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-3910
Practice Address - Country:US
Practice Address - Phone:619-420-6030
Practice Address - Fax:619-420-9102
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29371122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000475909OtherUNITED COCORDIA