Provider Demographics
NPI:1003877382
Name:GANDARA, LILLIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LILLIAN
Middle Name:
Last Name:GANDARA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7022 E NELSON DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-1718
Mailing Address - Country:US
Mailing Address - Phone:623-434-9343
Mailing Address - Fax:623-321-6268
Practice Address - Street 1:1904 W PARKSIDE LN
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1228
Practice Address - Country:US
Practice Address - Phone:623-434-9343
Practice Address - Fax:623-321-6268
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD59701223G0001X
TX200971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ830332Medicaid