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General NPI Number Information
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NPI Number | 1720184559
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Entity Type | Individual
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Provider Name | ENRICO MEDINA DDS
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Gender | Male
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 10142 S WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60643-1928
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Country | US
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Telephone | 773-233-3535
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Fax | 773-238-5713
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Provider Business Mailing Address
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Address Line | 2320 SIMSBURY CT
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City | NAPERVILLE
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State | IL
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Zip | 60564-9559
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Country | US
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Telephone | 630-904-4030
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Fax | 773-238-5713
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | IL
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