Healthcare Provider Details

I. General information

NPI: 1245708866
Provider Name (Legal Business Name): JOE MEDELLIN DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8949 RESEDA BLVD STE 116
NORTHRIDGE CA
91324-3995
US

IV. Provider business mailing address

8949 RESEDA BLVD STE 116
NORTHRIDGE CA
91324-3995
US

V. Phone/Fax

Practice location:
  • Phone: 818-280-5596
  • Fax: 818-975-5596
Mailing address:
  • Phone: 818-280-5596
  • Fax: 818-975-5596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JOE MEDELLIN
Title or Position: OWNER
Credential: DDS
Phone: 818-280-5596