Healthcare Provider Details

I. General information

NPI: 1588663694
Provider Name (Legal Business Name): CECIL C SANDOVAL DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DALIES AVE
BELEN NM
87002-3615
US

IV. Provider business mailing address

601 DALIES AVE
BELEN NM
87002-3615
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-8912
  • Fax: 505-864-2157
Mailing address:
  • Phone: 505-864-8912
  • Fax: 505-864-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD1452
License Number StateNM

VIII. Authorized Official

Name: CECIL C SANDOVAL
Title or Position: DENTIS
Credential: DDS
Phone: 505-864-8912