Provider Demographics
NPI:1174103667
Name:CASTILLO, JESUS RAFAEL (DDS)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:RAFAEL
Last Name:CASTILLO
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 COFFEE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1768
Mailing Address - Country:US
Mailing Address - Phone:209-529-2726
Mailing Address - Fax:
Practice Address - Street 1:3125 COFFEE RD STE 1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1768
Practice Address - Country:US
Practice Address - Phone:209-529-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1096551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program