Provider Demographics
NPI:1093553042
Name:ESTOESTA, MARA KAMILA A (DMD)
Entity type:Individual
Prefix:
First Name:MARA KAMILA
Middle Name:A
Last Name:ESTOESTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1283
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-1283
Mailing Address - Country:US
Mailing Address - Phone:209-479-2405
Mailing Address - Fax:
Practice Address - Street 1:1208 W TOKAY ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3810
Practice Address - Country:US
Practice Address - Phone:209-334-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1090961223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice