Healthcare Provider Details

I. General information

NPI: 1497855563
Provider Name (Legal Business Name): JESUS M MEDINA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11868 BANDERA RD
HELOTES TX
78023-4132
US

IV. Provider business mailing address

11868 BANDERA RD
HELOTES TX
78023-4132
US

V. Phone/Fax

Practice location:
  • Phone: 210-695-1738
  • Fax: 210-695-1736
Mailing address:
  • Phone: 210-695-1738
  • Fax: 210-695-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20136
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: