Provider Demographics
NPI:1992078455
Name:ESPEJO, MICHELLE (RDA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ESPEJO
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 D ST # B
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-1942
Mailing Address - Country:US
Mailing Address - Phone:619-201-4123
Mailing Address - Fax:
Practice Address - Street 1:4058 WILLOWS RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1668
Practice Address - Country:US
Practice Address - Phone:619-445-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73392126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant