Provider Demographics
NPI:1245060136
Name:IBARRA, JUAN (DDS)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:IBARRA
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 1:20721 S PENDLETON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93656-9238
Mailing Address - Country:US
Mailing Address - Phone:559-284-4151
Mailing Address - Fax:
Practice Address - Street 1:2610 TUOLUMNE ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1227
Practice Address - Country:US
Practice Address - Phone:800-492-4227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist