Healthcare Provider Details

I. General information

NPI: 1417891888
Provider Name (Legal Business Name): SIERRA MADISON SIBLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 W ARROW HWY
SAN DIMAS CA
91773-2958
US

IV. Provider business mailing address

11129 S KESTREL RISE RD
SOUTH JORDAN UT
84009-5167
US

V. Phone/Fax

Practice location:
  • Phone: 909-525-4636
  • Fax:
Mailing address:
  • Phone: 623-606-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: