Healthcare Provider Details

I. General information

NPI: 1053558882
Provider Name (Legal Business Name): SANDRA CORONA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W IVESBROOK AVE APT 117
LANCASTER CA
93534-2592
US

IV. Provider business mailing address

44558 10TH ST W
LANCASTER CA
93534-3333
US

V. Phone/Fax

Practice location:
  • Phone: 661-945-7736
  • Fax:
Mailing address:
  • Phone: 661-723-1111
  • Fax: 661-726-0587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number71964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: