Healthcare Provider Details

I. General information

NPI: 1477093201
Provider Name (Legal Business Name): ROXANA ESTRADA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23678-B LUISA MARTINEZ MARIANO MATAMOROS
TIJUANA BAJA CALIFORNIA
22206
MX

IV. Provider business mailing address

4275 EXECUTIVE SQ SUITE 200
LA JOLLA CA
92037-9123
US

V. Phone/Fax

Practice location:
  • Phone: 664-381-5245
  • Fax: 866-488-3200
Mailing address:
  • Phone: 619-488-3200
  • Fax: 866-272-6924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7729009
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8567994
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: