Healthcare Provider Details

I. General information

NPI: 1083138481
Provider Name (Legal Business Name): ESPINO & MEDINA DDS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 UNIVERSITY AVE.
RIVERSIDE CA
92507
US

IV. Provider business mailing address

P.O. BOX 71126
RIVERSIDE CA
92513
US

V. Phone/Fax

Practice location:
  • Phone: 951-289-9198
  • Fax:
Mailing address:
  • Phone: 818-815-1229
  • Fax: 951-588-8552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number57425
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID O. MEDINA
Title or Position: PRESIDENT
Credential: DDS
Phone: 818-815-1229