Healthcare Provider Details

I. General information

NPI: 1780292680
Provider Name (Legal Business Name): BASTIAN ANDRES ROJAS ESPINOZA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 N VETERANS PKWY STE 1
BLOOMINGTON IL
61704-0916
US

IV. Provider business mailing address

1507 N VETERANS PKWY STE 1
BLOOMINGTON IL
61704-0916
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-6666
  • Fax:
Mailing address:
  • Phone: 309-664-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033929
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD00146
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number12836
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: