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NPI Code Detail

MEDICARE: JESUS MEDINA JR. DDS

MEDICARE: JESUS MEDINA JR. DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice DentistryNV 2512NV

General Provider Information

NPI Number : 1134214067
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESUS MEDINA JR. DDS
Provider Business Mailing Address
First Line : 2911 N TENAYA WAY STE 101
Second Line :
City : LAS VEGAS
State : NV
Zip : 89128-0488
Country : US
Telephone Number : 702-368-3627
Fax Number : 702-368-3635
Provider Business Practice Location Address
First Line : 2911 N TENAYA WAY STE 101
Second Line :
City : LAS VEGAS
State : NV
Zip : 89128-0488
Country : US
Telephone Number : 702-368-3627
Fax Number : 702-368-3635
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2006
Last Update Date : 07/08/2007

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