Provider Demographics
NPI:1659046126
Name:ESPINO, ROAN FLORES
Entity Type:Individual
Prefix:MR
First Name:ROAN
Middle Name:FLORES
Last Name:ESPINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15956 E 14TH ST APT 107
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-3047
Mailing Address - Country:US
Mailing Address - Phone:415-342-5661
Mailing Address - Fax:
Practice Address - Street 1:15956 E 14TH ST APT 107
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-3047
Practice Address - Country:US
Practice Address - Phone:415-942-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP831124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist