Healthcare Provider Details

I. General information

NPI: 1851995229
Provider Name (Legal Business Name): MISS GRACIELA REBECA MEDINA II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7352 MEADE CT
FONTANA CA
92336-5439
US

IV. Provider business mailing address

7352 MEADE CT
FONTANA CA
92336-5439
US

V. Phone/Fax

Practice location:
  • Phone: 909-613-0106
  • Fax:
Mailing address:
  • Phone: 909-435-1376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number88142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: