Provider Demographics
NPI:1932830965
Name:OLGUIN MEDINA, MARIO ALBERTO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ALBERTO
Last Name:OLGUIN 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 1:409 UNIVERSITY AVE SE APT 26
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-1727
Mailing Address - Country:US
Mailing Address - Phone:612-850-2408
Mailing Address - Fax:
Practice Address - Street 1:3650 BRADDOCK AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-3681
Practice Address - Country:US
Practice Address - Phone:763-270-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist