MEDICARE: DR. BULMARIO MEDINA GONZALEZ DDS, FAACP, IBO

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	35400	CA

General Provider Information

NPI Number	:	1932398781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BULMARIO MEDINA GONZALEZ DDS, FAACP, IBO

Provider Business Mailing Address
First Line	:	7950 CHERRY AVE
Second Line	:	SUITE 101
City	:	FONTANA
State	:	CA
Zip	:	92336-4022
Country	:	US
Telephone Number	:	909-854-5400
Fax Number	:	909-854-6941

Provider Business Practice Location Address
First Line	:	7950 CHERRY AVE
Second Line	:	SUITE 101
City	:	FONTANA
State	:	CA
Zip	:	92336-4022
Country	:	US
Telephone Number	:	909-854-5400
Fax Number	:	909-854-6941

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

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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