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General NPI Number Information
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NPI Number | 1598152803
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Entity Type | Individual
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Provider Name | DOMINIQUE J MEDINA
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Gender | Male
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Dates
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Enumeration Date | 04/24/2015
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 1000 W CARSON ST
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City | TORRANCE
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State | CA
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Zip | 90502-2004
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Country | US
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Telephone | 424-306-4040
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Fax |
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Provider Business Mailing Address
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Address Line | 3181 SW SAM JACKSON PARK ROAD OHSU
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City | PORTLAND
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State | OR
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Zip | 97239
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Country | US
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Telephone | 503-494-8211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 107247
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License Number State | CA
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