Provider Demographics
NPI:1679711444
Name:MEDINA, ALISSA (DMD)
Entity type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S CONROE MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4722
Mailing Address - Country:US
Mailing Address - Phone:936-539-4004
Mailing Address - Fax:936-521-3964
Practice Address - Street 1:2000 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-3600
Practice Address - Country:US
Practice Address - Phone:501-603-5357
Practice Address - Fax:501-265-0081
Is Sole Proprietor?:No
Enumeration Date:2009-01-31
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69161223G0001X
NJ22D1023799001223G0001X
TX263361223G0001X
MS4084-191223G0001X
AR42541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice