MEDICARE: ERIN MEDINA

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
1	122300000X	Dentist	36404	TX

General Provider Information

NPI Number	:	1134738156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN MEDINA

Provider Business Mailing Address
First Line	:	7510 E GRAND AVE APT 1304
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-4163
Country	:	US
Telephone Number	:	903-799-0553
Fax Number	:

Provider Business Practice Location Address
First Line	:	7510 E GRAND AVE APT 1304
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-4163
Country	:	US
Telephone Number	:	903-799-0553
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2020
Last Update Date	:	07/27/2020

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Directions to “ ERIN MEDINA ” Practice Location

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