Provider Demographics
NPI:1912163908
Name:MEDICI, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MEDICI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 S. BOWEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1810 S BOWEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013-3340
Practice Address - Country:US
Practice Address - Phone:817-274-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17974122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist