MEDICARE: DR. SANDRA CALLEROS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	35478	CA
2	122300000X	Dentist	35478	CA

General Provider Information

NPI Number	:	1316940315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA CALLEROS DDS

Provider Business Mailing Address
First Line	:	131 W GRAND AVE
Second Line	:	SUITE B
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3738
Country	:	US
Telephone Number	:	310-414-9564
Fax Number	:	310-414-9773

Provider Business Practice Location Address
First Line	:	131 W GRAND AVE
Second Line	:	SUITE B
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3738
Country	:	US
Telephone Number	:	310-414-9564
Fax Number	:	310-414-9773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	08/19/2015

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