Healthcare Provider Details

I. General information

NPI: 1093389900
Provider Name (Legal Business Name): JUSTINA O. ESUOLA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 S GRAND AVE
LOS ANGELES CA
90007-3304
US

IV. Provider business mailing address

11000 WEYBURN DR APT 701
LOS ANGELES CA
90024-2832
US

V. Phone/Fax

Practice location:
  • Phone: 213-699-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: