Basic Information
| Provider Information | |||||||||
| NPI: | 1619515343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | COMMANDING OFFICER 2D DENBN/NDC | ||||||||
| Address2: | PSC 20130 315 MCHUGH BLVD | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518479 | ||||||||
| Practice Location | |||||||||
| Address1: | COMMANDING OFFICER 2D DENBN/NDC | ||||||||
| Address2: | PSC 20130 315 MCHUGH BLVD | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285420130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | 9104518479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2019 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 11552303-9921 | UT | Y | Dental Providers | Dentist |
No ID Information.