Healthcare Provider Details

I. General information

NPI: 1932518628
Provider Name (Legal Business Name): SANDRA FOGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S 18TH ST
YAKIMA WA
98901-3654
US

IV. Provider business mailing address

1120 S 18TH ST
YAKIMA WA
98901-3654
US

V. Phone/Fax

Practice location:
  • Phone: 509-573-5530
  • Fax: 509-654-7012
Mailing address:
  • Phone: 509-573-5530
  • Fax: 509-654-7012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60880906
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD13066
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: