Provider Demographics
NPI:1649467291
Name:DANIEL T. ESTACIO, DDS, INC.
Entity type:Organization
Organization Name:DANIEL T. ESTACIO, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:TORIBIO
Authorized Official - Last Name:ESTACIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-247-3387
Mailing Address - Street 1:1140 E CHEVY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2511
Mailing Address - Country:US
Mailing Address - Phone:818-247-3387
Mailing Address - Fax:818-247-2680
Practice Address - Street 1:1140 E CHEVY CHASE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2511
Practice Address - Country:US
Practice Address - Phone:818-247-3387
Practice Address - Fax:818-247-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47886305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG-93853-01OtherMEDI-CAL PROVIDER NO