Provider Demographics
NPI:1245258565
Name:ESTRADA, LUIS ANGEL (DDS)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANGEL
Last Name:ESTRADA
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 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:352-429-1257
Practice Address - Street 1:1296 W BROAD ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-2012
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:352-429-1257
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN139461223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0757934-00Medicaid