MEDICARE: SANDRA MICHELLE HENRIQUEZ RDHAP

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	124Q00000X	Dental Hygienist	698	CA

General Provider Information

NPI Number	:	1972097483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA MICHELLE HENRIQUEZ RDHAP

Provider Business Mailing Address
First Line	:	3163 IVY ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3212
Country	:	US
Telephone Number	:	310-694-7421
Fax Number	:	310-839-7367

Provider Business Practice Location Address
First Line	:	3163 IVY ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3212
Country	:	US
Telephone Number	:	310-694-7421
Fax Number	:	310-839-7367

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

Provider Enumeration Date	:	06/18/2018
Last Update Date	:	06/18/2018

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