Provider Demographics
NPI:1790169613
Name:ESMERALDO, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:ESMERALDO
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 1:42210 LYNDIE LN STE B
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3604
Mailing Address - Country:US
Mailing Address - Phone:951-695-5678
Mailing Address - Fax:951-695-5264
Practice Address - Street 1:42210 LYNDIE LN STE B
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-3604
Practice Address - Country:US
Practice Address - Phone:951-695-5678
Practice Address - Fax:951-695-5264
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31453122300000X
CA1025361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist