Provider Demographics
NPI:1730812959
Name:MOLINA MONGE, ESTEBAN SANTIAGO (DDS, CAGS)
Entity type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:SANTIAGO
Last Name:MOLINA MONGE
Suffix:
Gender:M
Credentials:DDS, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25090 WOODWARD AVE APT 112
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0981
Mailing Address - Country:US
Mailing Address - Phone:617-938-9313
Mailing Address - Fax:
Practice Address - Street 1:2700 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-2576
Practice Address - Country:US
Practice Address - Phone:313-494-6615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601672390200000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program