Provider Demographics
NPI:1427529601
Name:MEDINA & OLIVA DENTAL PC
Entity type:Organization
Organization Name:MEDINA & OLIVA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALEJANDRO
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-647-0907
Mailing Address - Street 1:1932 BELGRAVE DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3995
Mailing Address - Country:US
Mailing Address - Phone:425-647-0907
Mailing Address - Fax:
Practice Address - Street 1:925 CORPORATE CNTR PKWY STE G
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5453
Practice Address - Country:US
Practice Address - Phone:425-647-0907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental