Provider Demographics
NPI:1750878179
Name:ESTRADA, SANDRA IRENE (RDA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:IRENE
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2224
Mailing Address - Country:US
Mailing Address - Phone:951-532-4668
Mailing Address - Fax:
Practice Address - Street 1:1171 E BIXBY RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4125
Practice Address - Country:US
Practice Address - Phone:562-595-9131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41790126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant