Basic Information
| Provider Information | |||||||||
| NPI: | 1831782937 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESTERO SMILES DENTISTRY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 3039520892 | ||||||||
| Practice Location | |||||||||
| Address1: | 19521 HIGHLAND OAKS DRIVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392448853 | ||||||||
| FaxNumber: | 2392441230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2021 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | PHAM | ||||||||
| AuthorizedOfficialFirstName: | MINH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2392448853 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.