Provider Demographics
NPI:1497326953
Name:ESTRADA, JOSE LUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 LACY LN APT 16
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-7325
Mailing Address - Country:US
Mailing Address - Phone:225-384-0781
Mailing Address - Fax:
Practice Address - Street 1:729 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1603
Practice Address - Country:US
Practice Address - Phone:719-542-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002048231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice