Provider Demographics
NPI:1205394863
Name:WINTERS, SARAH GRACE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:GRACE
Last Name:WINTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ROBLEDA DR
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-3924
Mailing Address - Country:US
Mailing Address - Phone:650-393-3478
Mailing Address - Fax:
Practice Address - Street 1:324 N SAN MATEO DR STE 3
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2999
Practice Address - Country:US
Practice Address - Phone:650-342-6649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-03
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA105032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program