Provider Demographics
NPI:1093952202
Name:GONZALEZ, SARA (RDA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 BALHAM AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-6109
Mailing Address - Country:US
Mailing Address - Phone:626-581-0708
Mailing Address - Fax:
Practice Address - Street 1:4000 LA RICA AVE STE D
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3163
Practice Address - Country:US
Practice Address - Phone:626-430-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59939126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant