Provider Demographics
NPI:1821078635
Name:ESPINOZA, JUAN IGNACIO (DMD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:IGNACIO
Last Name:ESPINOZA
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 1:324 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-455-5385
Mailing Address - Fax:215-455-5385
Practice Address - Street 1:324 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120
Practice Address - Country:US
Practice Address - Phone:215-455-5385
Practice Address - Fax:215-455-5385
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028182L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1429293Medicare ID - Type Unspecified