Healthcare Provider Details

I. General information

NPI: 1497219604
Provider Name (Legal Business Name): SANDRA YANIRA GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA YANIRA GOMEZ

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 LA SIERRA AVE STE 108
RIVERSIDE CA
92503-5225
US

IV. Provider business mailing address

12665 SERRANO DR
YUCAIPA CA
92399-1744
US

V. Phone/Fax

Practice location:
  • Phone: 951-465-6982
  • Fax:
Mailing address:
  • Phone: 714-559-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA78245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: