Provider Demographics
NPI:1780292680
Name:ROJAS ESPINOZA, BASTIAN ANDRES (DDS)
Entity type:Individual
Prefix:DR
First Name:BASTIAN
Middle Name:ANDRES
Last Name:ROJAS ESPINOZA
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 1:1507 N VETERANS PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-0916
Mailing Address - Country:US
Mailing Address - Phone:309-664-6666
Mailing Address - Fax:
Practice Address - Street 1:1507 N VETERANS PKWY STE 1
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0916
Practice Address - Country:US
Practice Address - Phone:309-664-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12836390200000X
IL019.0339291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program