Provider Demographics
NPI:1477093201
Name:ESTRADA, ROXANA (DDS)
Entity Type:Individual
Prefix:
First Name:ROXANA
Middle Name:
Last Name:ESTRADA
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 1:4275 EXECUTIVE SQ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:23678-B LUISA MARTINEZ
Practice Address - Street 2:MARIANO MATAMOROS
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22206
Practice Address - Country:MX
Practice Address - Phone:664-381-5245
Practice Address - Fax:866-488-3200
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ7729009122300000X
ZZ85679941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics