Provider Demographics
NPI:1497008312
Name:SANDIA PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SANDIA PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANEN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SJOSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:614-949-9685
Mailing Address - Street 1:7007 WYOMING BLVD NE STE C-2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3987
Mailing Address - Country:US
Mailing Address - Phone:505-200-3516
Mailing Address - Fax:
Practice Address - Street 1:7007 WYOMING BLVD NE STE C-2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3987
Practice Address - Country:US
Practice Address - Phone:505-200-3516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD36471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty