Healthcare Provider Details

I. General information

NPI: 1730300039
Provider Name (Legal Business Name): TAWANA M. MEDLIN D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 HARKER AVE
BERLIN NJ
08009-2331
US

IV. Provider business mailing address

19 HARKER AVE
BERLIN NJ
08009-2331
US

V. Phone/Fax

Practice location:
  • Phone: 856-768-3332
  • Fax:
Mailing address:
  • Phone: 856-768-3332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02944300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberG1-0001168
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: