Healthcare Provider Details

I. General information

NPI: 1114436854
Provider Name (Legal Business Name): IVAN ALEJANDRO MEDINA-MARTINEZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 01/16/2022
Certification Date: 01/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 WILSON RD
BAKERSFIELD CA
93309-5208
US

IV. Provider business mailing address

3400 WIBLE RD
BAKERSFIELD CA
93309-6507
US

V. Phone/Fax

Practice location:
  • Phone: 661-741-0310
  • Fax: 661-349-9980
Mailing address:
  • Phone: 661-835-8672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number102012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: