Provider Demographics
NPI:1255865705
Name:SANDY I DIZON JR, DDS, INC
Entity Type:Organization
Organization Name:SANDY I DIZON JR, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:INTON
Authorized Official - Last Name:DIZON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-476-2821
Mailing Address - Street 1:9640 MILLIKEN AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-9000
Mailing Address - Country:US
Mailing Address - Phone:909-476-2821
Mailing Address - Fax:909-476-2805
Practice Address - Street 1:9640 MILLIKEN AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-9000
Practice Address - Country:US
Practice Address - Phone:909-476-2821
Practice Address - Fax:909-476-2805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty