MEDICARE: IVAN MEDINA-MARTINEZ DDS, INC.

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	261QD0000X	Dental Clinic/Center	102012	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102012	OTHER	CA	CALIFORNIA DENTAL BOARD
2	1114436854	OTHER	CA	NPI TYPE 1

General Provider Information

NPI Number	:	1467945212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVAN MEDINA-MARTINEZ DDS, INC.

Provider Business Mailing Address
First Line	:	3403 WILSON RD
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93309-5208
Country	:	US
Telephone Number	:	661-489-0678
Fax Number	:

Provider Business Practice Location Address
First Line	:	2122 BRUNDAGE LN
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93304-2702
Country	:	US
Telephone Number	:	661-437-6877
Fax Number	:	661-349-9980

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IVAN ALEJANDRO MEDINA-MARTINEZ
Credential	:	DDS
Telephone Number	:	661-437-6877

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	03/07/2023

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