Provider Demographics
NPI:1134334113
Name:ESTANQUE, RODOLFO (RUDY) J (DDS)
Entity type:Individual
Prefix:
First Name:RODOLFO (RUDY)
Middle Name:J
Last Name:ESTANQUE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E REDLANDS BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6168
Mailing Address - Country:US
Mailing Address - Phone:909-798-1900
Mailing Address - Fax:909-307-9430
Practice Address - Street 1:700 E REDLANDS BLVD STE J
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6168
Practice Address - Country:US
Practice Address - Phone:909-798-1900
Practice Address - Fax:909-307-9430
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA417221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92695 01OtherDENTICAL
CA20-8625749OtherEMPLOYER ID NUMBER