Healthcare Provider Details

I. General information

NPI: 1215562384
Provider Name (Legal Business Name): HDP SANDSTROM DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7448 E MAIN ST
MESA AZ
85207-8306
US

IV. Provider business mailing address

7448 E MAIN ST
MESA AZ
85207-8306
US

V. Phone/Fax

Practice location:
  • Phone: 480-376-2415
  • Fax:
Mailing address:
  • Phone: 480-376-2415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PAOLA RAMOS
Title or Position: CREDENTIALING LEAD
Credential:
Phone: 972-869-3789