Provider Demographics
NPI:1376639567
Name:VILLASENOR FASS, GLORIA ESTELA (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:ESTELA
Last Name:VILLASENOR FASS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MCHENRY AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0568
Mailing Address - Country:US
Mailing Address - Phone:209-526-9188
Mailing Address - Fax:209-409-8608
Practice Address - Street 1:140 MCHENRY AVE STE 5
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0568
Practice Address - Country:US
Practice Address - Phone:209-526-9188
Practice Address - Fax:209-409-8608
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48403122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist