Healthcare Provider Details

I. General information

NPI: 1508936709
Provider Name (Legal Business Name): CARLOS MANUEL ESPANA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 WILLOW ST #101
BONITA CA
91902-1349
US

IV. Provider business mailing address

145 WILLOW ST #101
BONITA CA
91902-1349
US

V. Phone/Fax

Practice location:
  • Phone: 619-479-1942
  • Fax: 619-479-1192
Mailing address:
  • Phone: 619-479-1942
  • Fax: 619-479-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37658
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: