Provider Demographics
NPI:1861629099
Name:MEDINA, AMANDA R (DENTAL ASSISTANT)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:R
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DENTAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 PATTERSON RD
Mailing Address - Street 2:APARTMENT #2
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-4319
Mailing Address - Country:US
Mailing Address - Phone:937-344-4291
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:SUITE 2070
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1898
Practice Address - Country:US
Practice Address - Phone:937-641-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH008451223P0221X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
No1223P0221XDental ProvidersDentistPediatric Dentistry