Provider Demographics
NPI:1164150645
Name:COTA, SANDRA LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:COTA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:KANDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:292 NW MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-9186
Mailing Address - Country:US
Mailing Address - Phone:541-678-3403
Mailing Address - Fax:
Practice Address - Street 1:1270 KOT-NUM ROAD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761
Practice Address - Country:US
Practice Address - Phone:541-553-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3303124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH3303OtherOREGON BOARD OF DENTISTRY, DENTAL HYGIENE LICENSE