Healthcare Provider Details

I. General information

NPI: 1710409339
Provider Name (Legal Business Name): MARIA AHLEEN DE LEON MEDINA DMD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 07/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 MADISON AVE STE 3
CARMICHAEL CA
95608-0645
US

IV. Provider business mailing address

4900 BRITTANY CT
ROCKLIN CA
95677-4446
US

V. Phone/Fax

Practice location:
  • Phone: 916-276-8629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JONNEL MEDINA
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 916-276-8629