Active NPI
Jaqueline Medina, DDS
- General Practice Dentistry
- Port Arthur, TX
National Provider Identifier
1477167419
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 36599
- Practice address
- 2780 FM 365
Suite C
Port Arthur, TX 77640 - Phone
- (409) 332-4701
- NPI assigned
- Sep 8, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 36599 | TX | Primary |
Addresses
Primary practice location
2780 FM 365
Suite C
Port Arthur, TX 77640
Mailing address
4700 Santa Fe Ave
Dallas, TX 75223-2131
Phone (469) 571-1942
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 36599 | TX | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1599523200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1599523200000",
"number": "1477167419",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4700 SANTA FE AVE",
"city": "DALLAS",
"state": "TX",
"postal_code": "752232131",
"telephone_number": "469-571-1942"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2780 FM 365",
"address_2": "SUITE C",
"city": "PORT ARTHUR",
"state": "TX",
"postal_code": "77640",
"telephone_number": "409-332-4701"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MEDINA",
"first_name": "JAQUELINE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-09-08",
"last_updated": "2020-09-08",
"certification_date": "2020-09-02",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "TX",
"license": "36599",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Port Arthur, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.