Healthcare Provider Details

I. General information

NPI: 1891677951
Provider Name (Legal Business Name): YURY NATALIA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 MAIN ST
SPRINGFIELD MA
01103-2114
US

IV. Provider business mailing address

1049 MAIN ST
SPRINGFIELD MA
01103-2114
US

V. Phone/Fax

Practice location:
  • Phone: 413-739-1100
  • Fax: 413-735-1133
Mailing address:
  • Phone: 413-739-1100
  • Fax: 413-735-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL101140
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberDA03071
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: