Healthcare Provider Details

I. General information

NPI: 1538094768
Provider Name (Legal Business Name): SALLY CAHYADI GONZAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BERNARDO AVE
MORRO BAY CA
93442-2339
US

IV. Provider business mailing address

1537 CINDEE LN
COLTON CA
92324-4843
US

V. Phone/Fax

Practice location:
  • Phone: 805-772-8585
  • Fax:
Mailing address:
  • Phone: 909-771-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: