Healthcare Provider Details

I. General information

NPI: 1053090217
Provider Name (Legal Business Name): SARAH SOURIALLE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E HIGHLAND AVE STE 120
SAN BERNARDINO CA
92404-3812
US

IV. Provider business mailing address

9 SAINT RAPHAEL
LAGUNA NIGUEL CA
92677-2761
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-0645
  • Fax:
Mailing address:
  • Phone: 909-732-7487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: