Provider Demographics
NPI:1598452955
Name:MEDINA-ROBLES, JOSE FERNANDO (DMD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:FERNANDO
Last Name:MEDINA-ROBLES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413
Mailing Address - Country:US
Mailing Address - Phone:407-724-0336
Mailing Address - Fax:
Practice Address - Street 1:236 OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:407-724-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY064037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program