=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134834518
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDOVAL AYALA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2023
-----------------------------------------------------
Last Update Date | 01/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8191 SOUTHWEST FWY STE 108
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77074-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-679-0532
-----------------------------------------------------
Fax | 713-485-4389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8191 SOUTHWEST FWY STE 108
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77074-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-679-0532
-----------------------------------------------------
Fax | 713-485-4389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST /OWNER
-----------------------------------------------------
Name | ROBERTO M SANDOVAL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 832-679-0532
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------