Provider Demographics
NPI:1053934778
Name:MEDRANO, ANA DINA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:DINA
Last Name:MEDRANO
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 1:14595 PIEDMONT DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-5740
Mailing Address - Country:US
Mailing Address - Phone:951-489-8120
Mailing Address - Fax:951-247-1170
Practice Address - Street 1:763 RIO RANCHO RD STE 120
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-7015
Practice Address - Country:US
Practice Address - Phone:909-242-7989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60484126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA60484Medicaid