Healthcare Provider Details

I. General information

NPI: 1679366140
Provider Name (Legal Business Name): BRIANDA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1471 CHESTER BLVD STE B
RICHMOND IN
47374-1946
US

IV. Provider business mailing address

5051 BASSETT DR
INDIANAPOLIS IN
46235-3378
US

V. Phone/Fax

Practice location:
  • Phone: 765-962-4774
  • Fax:
Mailing address:
  • Phone: 317-205-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12015072A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: