Healthcare Provider Details

I. General information

NPI: 1710553367
Provider Name (Legal Business Name): MARIA KAY SANDOVAL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9323 MENCHACA RD APT 921
AUSTIN TX
78748-6253
US

IV. Provider business mailing address

9323 MENCHACA RD APT 921
AUSTIN TX
78748-6253
US

V. Phone/Fax

Practice location:
  • Phone: 765-610-7797
  • Fax:
Mailing address:
  • Phone: 765-610-7797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number17618
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: